Health Policy - Articles in Press

Provision and financing of assistive technology devices in Germany: A bureaucratic odyssey? The case of amyotrophic lateral sclerosis and Duchenne muscular dystrophy - Corrected Proof

Cornelia Henschke — 2012-02-21

Abstract: Objective: The regulations for financing assistive technology devices (ATDs) are complex and fragmented and, thus, might influence adequate provision of these devices to people who need multiple ATDs. This study aims to explore and analyze patients’ problems with the provision and financing of ATDs for the following two rare diseases: amyotrophic lateral sclerosis (ALS) and Duchenne muscular dystrophy (DMD).Methods: A survey was conducted by means of semi-standardized questionnaires addressing the issues of coverage decisions for ATDs and problems with provision of ATDs. Information was retrieved from ALS (n=19) and DMD (n=14) patients. Conducted interviews were transcribed verbatim and analyzed using qualitative content analysis.Results: Respondents experienced difficulties with the provision and financing of ATDs. They underlined problems such as long approval processes and a serious bureaucratic burden, which induced inadequate provision of ATDs. Experiences of ALS and DMD respondents frequently were similar, especially regarding financing decisions and the process of decision making by sickness funds.Conclusion: The results suggest that difficulties in receiving and financing ATDs are common problems among ALS and DMD patients. There is a need for an interdisciplinary approach in the provision of ATDs and their financing, which should be coordinated by case managers.

A framework to evaluate the effects of small area variations in healthcare infrastructure on diagnostics and patient outcomes of rare diseases based on administrative data - Corrected Proof

Tom Stargardt, Jonas Schreyögg — 2012-02-20

Abstract: Introduction: Small area variations in healthcare infrastructure may result in differences in early detection and outcomes for patients with rare diseases.Methods: It is our aim to provide a framework for evaluating small area variations in healthcare infrastructure on the diagnostics and health outcomes of rare diseases. We focus on administrative data as it allows (a) for relatively large sample sizes even though the prevalence of rare diseases is very low, and (b) makes it possible to link information on healthcare infrastructure to morbidity, mortality, and utilization.Results: For identifying patients with a rare disease in a database, a combination of different classification systems has to be used due to usually multiple diseases sharing one ICD code. Outcomes should be chosen that are (a) appropriate for the disease, (b) identifiable and reliably coded in the administrative database, and (c) observable during the limited time period of the follow-up. Risk adjustment using summary scores of disease-specific or comprehensive risk adjustment instruments might be preferable over empirical weights because of the lower number of variables needed.Conclusion: The proposed framework will help to identify differences in time to diagnosis and treatment outcomes across areas in the context of rare diseases.

Critical urban areas, deprived areas and neighbourhood effects on health in France - Corrected Proof

Thierry Debrand, Aurélie Pierre, Caroline Allonier, Véronique Lucas-Gabrielli — 2012-02-17

Abstract: Since the 1980s, different French governments have formulated public policies aimed at taking into account the specific problems of deprived neighbourhoods. The aim of this paper is to determinate the existence of a neighbourhood effect on health and to discuss the implementation of a geographical index of deprived areas in France. Using the National Health Survey of 2002–2003 and 1999 French census data, we attempt to measure the individual and collective determinants of Self-Reported Health Status (SRH). By using a principal component analysis of aggregated census data, we obtain three synthetic factors: “economic and social condition”, “residential stability” and “generational”, and show that these contextual factors are correlated with individual SRH. Our research shows that health inequalities cannot be tackled by using only the Critical Urban Area criterion (the fact of living in a CUA or not) because some inequalities remain ignored and thus, hidden. We suggest a methodology to build a new health deprivation index allowing to better target health inequalities.

Study-design selection criteria in systematic reviews of effectiveness of health systems interventions and reforms: A meta-review - Corrected Proof

2012-02-13

Abstract: At present, there exists no widely agreed upon set of study-design selection criteria for systematic reviews of health systems research, except for those proposed by the Cochrane Collaboration's Effective Practice and Organisation of Care (EPOC) review group (which comprises randomized controlled trials, controlled clinical trials, controlled before-after studies, and interrupted time series). We conducted a meta-review of the study-design selection criteria used in systematic reviews available in the McMaster University's Health Systems Evidence or the EPOC database. Of 414 systematic reviews, 13% did not indicate any study-design selection criteria. Of the 359 studies that described such criteria, 50% limited their synthesis to controlled trials and 68% to some or all of the designs defined by the EPOC criteria. Seven out of eight reviews identified at least one controlled trial that was relevant for the review topic. Seven percent of the reviews included either no or only one relevant primary study. Our meta-review reveals reviewers’ preferences for restricting synthesis to controlled experiments or study designs that comply with the EPOC criteria. We discuss the advantages and disadvantages of the current practices regarding study-design selection in systematic reviews of health systems research as well as alternative approaches.

Japan's policy of promoting end-of-life care in nursing homes: Impact on facility and resident characteristics associated with the site of death - Corrected Proof

Naoki Ikegami, Sumie Ikezaki — 2012-02-13

Abstract: Objective: To evaluate the impact of the policy to encourage nursing homes to provide end-of-life care by comparing facility and resident variables associated with dying within the nursing home and not in hospitals, and by comparing life sustaining treatment (LST) respectively provided.Method: Questionnaires mailed to an 11% random sample of 653 nursing homes in 2009. Facility characteristics from 371 nursing homes (57%) and resident characteristics of the 1158 who had been discharged due to death were obtained from 241 facilities (37%).Results: Facility characteristics related to dying in nursing homes were their policy of providing end-of-life care and physicians being based in home care supporting clinics. Resident characteristics related were not having pneumonia as the cause of death, the family's preference of the nursing home as the site of death and agreement within the family. Preferences on the use of LST were adhered more in residents who had died in nursing homes.Conclusion: Although the percentage of residents dying within the facility has increased, the nursing home as a site of death still composes only 3.2% of the total. To increase the latter, nursing homes should refocus their function to providing end-of-life care to those not preferring aggressive treatment.

Does team-based primary health care improve patients’ perception of outcomes? Evidence from the 2007–08 Canadian Survey of Experiences with Primary Health - Corrected Proof

Shammima Jesmin, Amardeep Thind, Sisira Sarma — 2012-02-10

Abstract: Background: Team-based practice in primary care has been advocated for improved access, quality, effectiveness, and cost-efficiency of primary health care services, but there is limited empirical evidence supporting it.Objective: To examine the impact of team-based practice on patients’ perception of several process and outcome indicators from patients’ perspective.Data and methods: Micro data from the 2007–08 Canadian Survey of Experiences with Primary Health Care conducted by Statistics Canada were utilized. Regression techniques and propensity score matching method were used to examine the impact of team-based primary care on several process and outcome indicators of primary care.Results: The estimated average treatment effect of team-based care was positively significant and robust for access to after-hours care, quality of care, confidence in the system, overall coordination of care, and patient centeredness. Although the estimated average treatment effects for the two dimensions of follow-up coordination, continuity of care, health promotion and disease prevention initiatives, and utilization of physician and nurse services were statistically significant, sensitivity test results showed that these results were unreliable.Conclusions: Team-based primary care improves patients’ perception of process and outcome indicators in the area of access to after-hours care, quality of care, confidence in the system, overall coordination and patient centeredness. Future research needs to establish the causal link between team-based primary care and health outcomes of patients.

Financial burden of drug expenditures in Poland - Corrected Proof

Julita Łuczak, Pilar García-Gómez — 2012-02-06

Abstract: Objectives: This paper investigates the level of catastrophic out-of-pocket pharmaceutical (OOP) expenditures and their impoverishment effect in Poland.Methods: We use data from a representative sample of Polish households covering 2000, 2003, 2005, 2007 and 2009. We estimate the incidence and intensity of catastrophic drug expenditure and its impoverishment effects using the methods introduced by Wagstaff and van Doorslaer. We obtain estimates for the full population and for the subsample of retired and chronically ill.Results: The incidence and intensity of catastrophic drug expenditures increased over the years and they are concentrated among the poor. The proportion of households that spent at least 10% of their income on pharmaceuticals reached 18% in 2009. This figure is higher than the evidence found in other countries for total health expenditure. Pharmaceutical expenditures increased poverty rates, and the evidence suggests that the poverty impact of OOP expenditures in the last decade was mainly driven by poor people becoming poorer. The effects are more conspicuous among the retired and chronically ill.Conclusions: Our findings indicate that OOP pharmaceutical expenditures in Poland are a severe financial burden and that policies aimed at both lowering the price of effective drugs and decreasing consumption of the ineffective ones are needed.

Responding to diversity: An exploratory study of migrant health policies in Europe - Corrected Proof

Philipa Mladovsky, Bernd Rechel, David Ingleby, Martin McKee — 2012-02-06

Abstract: There has been growing international attention to migrant health, reflecting recognition of the need for health systems to adapt to increasingly diverse populations. However, reports from health policy experts in 25 European countries suggest that by 2009 only eleven countries had established national policies to improve migrant health that go beyond migrants’ statutory or legal entitlement to care. The objective of this paper is to compare and contrast the content of these policies and analyse their strengths and limitations. The analysis suggests that most of the national policies target either migrants or more established ethnic minorities. Countries should address the diverse needs of both groups and could learn from “intercultural” health care policies in Ireland and, in the past, the Netherlands. Policies in several countries prioritise specific diseases or conditions, but these differ and it is not clear whether they accurately reflect real differences in need among countries. Policy initiatives typically involve training health workers, providing interpreter services and/or ‘cultural mediators’, adapting organizational culture, improving data collection and providing information to migrants on health problems and services. A few countries stand out for their quest to increase migrants’ health literacy and their participation in the development and implementation of policy. Progressive migrant health policies are not always sustainable as they can be undermined or even reversed when political contexts change. The analysis of migrant health policies in Europe is still in its infancy and there is an urgent need to monitor the implementation and evaluate the effectiveness of these diverse policies.

Fifty ways to reduce length of stay: An inventory of how hospital staff would reduce the length of stay in their hospital - Corrected Proof

Ine Borghans, Rudolf B. Kool, Ronald J. Lagoe, Gert P. Westert — 2012-02-03

Abstract: Purpose and setting: In this study we present a bottom up approach to developing interventions to shorten lengths of stay. Between 1999 and 2009 we applied the approach in 21 Dutch clinical wards in 12 hospitals. We present the complete inventory of all interventions.Design: We organised, on the hospital ward level, structured meetings with the staff in order to first identify barriers to reduce the length of stay and then later to link them to interventions. The key components of the approach were a benchmark with the fifteenth percentile and the use of a matrix, that on one side was arranged along the main phases of the care process – the admission, stay and discharge – and on the other side to the degree to which the length of stay could be shortened by the medical specialists and nurses themselves or by involving others.Findings and conclusions: The matrix consists of a wide variety of interventions that mainly cover what we found in published research. As a bottom up approach is more likely to succeed, we would advise wards that have to reduce length of stay to make the inventory themselves, using appropriate benchmark data, and by using the matrix.

Pediatric primary care services in Manitoba: Is the health of the next generation of children at risk? - Corrected Proof

Alan Katz, Bogdan Bogdanovic, Okechukwu Ekuma, Ruth-Ann Soodeen, Jennifer Enns — 2012-02-03

Abstract: Objectives: Physician resource planning is an important part of health policy, but to date there are no studies measuring the primary care service needs of a particular population. The aim of this study was to project the expected provision of physician services for the pediatric population of one Canadian province for 2020.Methods: A novel standardized measure of physician service provision, the equivalent services measure, was developed using mathematical modeling. Population projections and past use of services were used to calculate the projected service needs for the pediatric population of Manitoba.Results: Despite projecting a small increase in the pediatric population (2.8%), our model predicted a decrease of 13.4% in the services that would be provided.Conclusions: The findings of this study indicate that the health of future generations of children may be at risk. Further research is needed to determine the effect of the reduction in pediatric service provision on the health of the pediatric population.

Does healthcare infrastructure have an impact on delay in diagnosis and survival? - Corrected Proof

Carl Rudolf Blankart — 2012-02-01

Abstract: Introduction: The objectives of this study were to evaluate whether healthcare infrastructure impacts delay in diagnosis, and to determine whether healthcare infrastructure and delay in diagnosis impacts survival in gastric cancer.Methods: Administrative data from 2175 gastric cancer patients was analyzed using two Cox proportional hazard models with (i) delay in diagnosis and (ii) survival as dependent variables. Density of general practitioners, density of gastroenterologists, characteristics of specialty treatment centers, demographic information, and comorbidities were included in the models. Differentiation was made between urban and rural areas.Results: The likelihood of being diagnosed increased with an increase in general practitioners (p<0.0001) and gastroenterologists (p<0.0001) in rural areas. In urban areas a higher density of general practitioners reduced delay in diagnosis (p=0.0262), while a higher density of gastroenterologists did not (p=0.2480). The number of gastric cancer cases performed in hospital had a positive impact on survival (p<0.0001), while outpatient infrastructure did not.Conclusion: Delay in diagnosis can be reduced by higher availability of general practitioners and gastroenterologists in rural areas. Given the already very high density of physicians in urban areas there is no effect of additional gastroenterologists. As learning effects can be observed with increased hospital volumes, minimum volumes for treatment of gastric cancer may be defined.

Effects of the per diem prospective payment system with DRG-like grouping system (DPC/PDPS) on resource usage and healthcare quality in Japan - Corrected Proof

Hironori Hamada, Miho Sekimoto, Yuichi Imanaka — 2012-01-25

Abstract: Objectives: In 2003, Japan introduced the prospective payment system (PPS) with diagnosis-related groups (DRG) rearranged grouping system called the diagnostic procedure combination/per-diem payment system (DPC/PDPS). Even after eight years, little is known about the effects of DPC/PDPS. The purpose of this study was to examine the effects of DPC/PDPS on resource usage and healthcare quality.Methods: Using 2001–2009 (fiscal year) administrative data of acute myocardial infarction patients, four indices, including inpatient total accumulated medical charges, length of stay (LOS), mortality rate, and readmission rate, were compared between patients reimbursed by DPC/PDPS or by fee-for-service.Results: DPC/PDPS significantly reduced total accumulated medical charges by $1061 (95% confidence interval [CI], −2007, −116) and LOS by 2.29 days (95% CI, −3.71, −0.88) after risk adjustment. However, mortality rate (Odds ratio [OR], 0.94; 95% CI, 0.73, 1.21) was unchanged. Furthermore, DPC/PDPS increased the readmission rate (OR, 1.37; 95% CI, 1.03, 1.82).Conclusions: This study showed that DPC/PDPS was associated with reduced resource usage, but not improved healthcare quality, as with DRG/PPSs in other countries. To achieve successful healthcare reform, further discussion on additional motives will be required.

Monitoring migrant health in Europe: A narrative review of data collection practices - Corrected Proof

Bernd Rechel, Philipa Mladovsky, Walter Devillé — 2012-01-25

Abstract: Background: Data on the health of migrants, including on health determinants and access to health services, are an essential pre-condition for providing appropriate and accessible health services to this population group. This article reviews how far current data collection systems in the European Union (EU) allow to monitor migrant health.Methods: We searched the academic literature using PubMed and reviewed the results of recent EU-funded research projects on migrant health.Results: Most EU member states lack information on the health of migrants, limiting the possibility for monitoring and improving migrant health. National death registers allow for disaggregation according to migrant status in 24 of 27 EU member states. Registry data on health care utilization by migrant status are available in only 11 of 27 member states, although in most cases this only covers secondary and not primary care. Only few countries collect large-scale survey data on migrant health and health care utilization.Conclusion: Many EU countries need to step up their organizational and regulatory efforts to monitor migrant health if the current lack of data on migrant health should be overcome. This could be done through the inclusion of improved questions on migration in existing data collection processes.

Leadership and governance in seven developed health systems - Corrected Proof

2012-01-24

Abstract: This paper explores leadership and governance arrangements in seven developed health systems: Australia, England, Germany, the Netherlands, Norway, Sweden and Switzerland. It presents a cybernetic model of leadership and governance comprising three fundamental functions: priority setting, performance monitoring and accountability arrangements. The paper uses a structured survey to examine critically current arrangements in the seven countries. Approaches to leadership and governance vary substantially, and have to date been developed piecemeal and somewhat arbitrarily. Although there seems to be reasonable consensus on broad goals of the health system there is variation in approaches to setting priorities. Cost-effectiveness analysis is in widespread use as a basis for operational priority setting, but rarely plays a central role. Performance monitoring may be the domain where there is most convergence of thinking, although countries are at different stages of development. The third domain of accountability is where the greatest variation occurs, and where there is greatest uncertainty about the optimal approach. We conclude that a judicious mix of accountability mechanisms is likely to be appropriate in most settings, including market mechanisms, electoral processes, direct financial incentives, and professional oversight and control. The mechanisms should be aligned with the priority setting and monitoring processes.

Travelling home for treatment and EU patients’ rights to care abroad: Results of a survey among German students at Maastricht University - Corrected Proof

Irene A. Glinos, Nora Doering, Hans Maarse — 2012-01-20

Abstract: Empirical evidence on patient mobility in Europe is lacking despite widespread legal, policy and media attention which the phenomenon attracts. This paper presents quantitative data on the health care seeking behaviour of German students at Maastricht University in the Netherlands. A cross-sectional survey design was applied with a mixed-methods approach including open and closed questions. Questionnaire items were based on a theoretical model of patient mobility and input from focus group discussions with German students living in Maastricht. 235 valid surveys were completed, representing ca. 8% of the target population. Data collection took place in Oct–Dec 2010.Of respondents who received medical care over the last two years, 97% returned to Germany; of these, 76% travelled to their home city for medical treatment. 72% received care only in Germany, i.e. not even once in Maastricht. Distance partly influenced whether students travelled to Germany, returned home or stayed in Maastricht, and the type of care accessed. Key motivations were familiarity with home providers/system, and reimbursement issues.In the context of the new EU Directive on patients’ rights, the findings call into question whether Europeans use entitlements to cross-border care and what the real potential of patient mobility is. The results demonstrate the existence and magnitude of return movements as a sub-group of patient mobility.

Implementation of the Tallinn Charter in the WHO European region: Where is the evidence? a systematic comparison of online information before and after the end of the year of signature - Corrected Proof

Fabrizio Carinci — 2012-01-18

Abstract: Background: The “Tallinn Charter: Health Systems, Health and Wealth” signed by 53 member states of the WHO European Region provides guidance for strengthening health systems.Objectives: A systematic search was conducted to compare studies and actions related to the commitments of the Tallinn Charter.Materials and methods: Target keywords were identified directly from the Charter. Structured web search was conducted on Pubmed/Google. Results for 2007–2010 were analyzed as frequencies before/after the end of the year of signature and classified by relevance and category of content.Results: Searches for 2007–2010 extracted N=717 papers in Medline and N=634 links in Google using combined keywords. Additional N=165 direct links to the Charter were found by Google for 2008–2010. An increase by 18% (scientific literature) and 10% (grey literature) was observed after 2008.Discussion: The number of conceptual, methodological, analytical or system evaluation reports related to the themes of the Charter increased after 2008, while benchmarking and cross-country comparisons were less frequent. Opposite trends were observed for the grey literature.Conclusions: The implementation of the Tallinn Charter is supported by more information available on the topic. The methodology used to perform a rapid search may be usefully repeated to monitor the process.

Managing poorly performing clinicians: Health care providers’ willingness to pay for independent help - Corrected Proof

Verity Watson, Jon Sussex, Mandy Ryan, Ebenezer Tetteh — 2012-01-17

Abstract: Objective: To determine the willingness to pay (WTP) of senior managers in the UK National Health Service (NHS) for services to help manage performance concerns with doctors, dentists and pharmacists.Methods: A discrete choice experiment (DCE) was used to elicit senior managers’ preferences for a support service to help manage clinical performance concerns. The DCE was based on: a literature review; interviews with support service providers and clinical professional bodies; and discussion groups with managers. From the DCE responses, we estimate marginal WTP for aspects of support services.Results: 451 NHS managers completed the DCE questionnaire. NHS managers are willing to pay for: advice, ‘facilitation’, and behavioural, health, clinical and organisational assessments. Telephone advice with written confirmation was valued most highly. NHS managers were willing to pay £161.56 (CI: £160.81–£162.32) per year per whole time equivalent doctor, dentist or pharmacist, for support to help manage clinical performance concerns. Marginal WTP varied across respondent subgroups but was always positive.Conclusions: Health care managers valued help in managing the clinicians’ performance, and were willing to pay for it from their organisations’ limited funds. Their WTP exceeds the current cost of a UK body providing similar support. Establishing a central body to provide such services across a health care system, with the associated economies of scale including cumulative experience, is an option that policy makers should consider seriously.

Implementation of a service for physicians’ consultation and information in euthanasia requests in Belgium - Corrected Proof

2012-01-09

Abstract: Aim: To study the implementation of LEIF, the consultation service which provides access to specially trained physicians to act as the legally required second physician in requests for euthanasia in Flanders and Brussels, Belgium, the use of which has been to shown to be beneficial to the careful practice of euthanasia.Method: A representative sample of 3006 Belgian physicians from the area where LEIF is active received a questionnaire investigating their attitude and practice regarding euthanasia, asking about their knowledge of LEIF, their attitude towards the service, their use of the service and their intentions regarding its future use.Findings: Seventy-eight per cent of physicians knew about the existence of the organization, 90% felt supported by the idea of being able to consult a LEIF physician and 90% intended to use LEIF in the future. Only 35% of those who had received a euthanasia request since LEIF became active had made use of LEIF. Awareness, use and intended use of LEIF were lower among specific groups of physicians (e.g. specialists). Positive attitudes towards consultation and training were positively associated with future use of LEIF.Conclusion: Implementation can be considered successful but LEIF should continue promoting its services as widely as possible, with specific attention paid to specialists.

Stakeholder involvement in expensive drug recommendation decisions: An international perspective - Corrected Proof

2012-01-09

Abstract: Objectives: To describe stakeholder involvement in the priority setting and appeals processes across five drug reimbursement recommendation committees.Methods: We conducted qualitative case studies of how five independent drug advisory committees from Canada, Israel, England and Wales, Australia, and the USA made funding decisions for six expensive drugs. Interviews with 48 informants were conducted with committee members, patient groups, and industry representatives.Results: Different stakeholders were allowed, in varying degrees, to participate in the formal mechanisms for revisions and appeals of decisions. Participants identified a number of stakeholder groups who were already involved in the process, as well as stakeholders whom they believed should be included in the decision-making process.Conclusions: A central component of a legitimate and fair priority setting process is to make priority setting explicit and to involve both pertinent values and stakeholders in decision-making. Study participants believed that the involvement of multiple stakeholder groups within the deliberative and appeals/revisions processes would contribute to a fair and legitimate drug reimbursement process.

Perceptions and patterns of use of generic drugs among Italian Family Pediatricians: First round results of a web survey - Corrected Proof

2012-01-05

Abstract: Prescription of generic medicines represents an efficacious healthcare cost containment strategy. In some European countries and in the US, generic medicines are largely prescribed. In Italy, generic drugs prescription rate is lower. General Practitioners and Family Pediatricians may be less confident in prescribing generic equivalents instead of “branded” medicines. There are currently no data about Italian Family Pediatricians’ perceptions and patterns of use of generic drugs. This is a first nationwide web survey conducted with the aim to evaluate generic medicines knowledge and prescribing habits of Italian Family Pediatricians. 303 Family Pediatricians completed the online questionnaire. 37.2% and 32.6% of them declared to have a sufficient or fairly good knowledge of generic medicines, respectively, and the majority of them believed that efficacy of generic medicines was sufficient (33.6%) or good (45.2%). Nevertheless, Italian Family Pediatricians are still prone to prescribe trade medicines more frequently, since only 13.5% of them declared that more than a half of their patients were treated with generic medicines. Major issues related with generic medicines prescriptions by Italian Family Pediatricians seem to be represented by diffuse scepticism about reliability of bioequivalence tests and safety of switchability from branded to generic equivalents. More information about generic drugs and more research in the field of pediatric pharmacology are needed for increasing generic medicines prescription rate among Italian Family Pediatricians.

Giving to receive? The right to donate in umbilical cord blood banking for stem cell therapies - Corrected Proof

Laura L. Machin, Nik Brown, Danae McLeod — 2012-01-04

Abstract: Objectives: To explore the views of lay and professional stakeholders about the donation of cord blood to public banks in England and the policies surrounding it.Methods: Qualitative in-depth interviews were undertaken between April 2009 and August 2010 with 62 participants based in England who play a key role in cord blood banking and therapy. All interviews were recorded, transcribed in full, and coded and analysed thematically.Results: Participants claimed pregnant women had a right to know of the value of cord blood. This highlighted the flaws of the existing donation infrastructure, which was portrayed as playing a significant role in determining public health. Participants called for a right to donate cord blood to readdress the inequity in healthcare services for pregnant women and transplant recipients. Donors maintained a sense of right over their donation when they discussed cord blood donation as potentially benefiting their family as well as society.Conclusion: In order to keep receiving donated body parts, tissue and blood, there is a need to take into account the way in which donation operates within a prevalent ‘rights’ discourse.

Policies to improve the health and well-being of Roma people: The European experience - Corrected Proof

Gabriella Fésüs, Piroska Östlin, Martin McKee, Róza Ádány — 2012-01-04

Abstract: The Roma constitute the largest ethnic minority in the European Region. The many policy initiatives designed over the past two decades to tackle their adverse social conditions in Central and South Eastern Europe, where the Roma population is concentrated, have had limited success. This paper reviews what is being done to improve the health and social situation of Roma communities in the Region and identifies factors that may limit the effectiveness of these policy initiatives. Strong political commitment, measures to overcome prejudices against Roma, inter-sectoral policy coordination, adequate budgets, evidence-based policies, and Roma involvement can be identified as key preconditions for improved health outcomes and well-being. However, developing a sound evidence-based approach to Roma inclusion requires removing obstacles to the collection of reliable data and improving analytical and evaluation capacity. Health policies seeking to reduce health inequalities for Roma people need to be aligned with education, economic, labour market, housing, environmental and territorial development policies and form part of comprehensive policy frameworks allowing for effective integration.

Crossing borders: A critical review of the role of the European Court of Justice in EU health policy - Corrected Proof

Eleanor Brooks — 2012-01-04

Abstract: Over the last two decades, the European Union (EU) has steadily increased its involvement in the health policies of its member states, with considerable support from the European Court of Justice (ECJ). However, much of the literature examining the Court's role has focused upon the intersection between internal market law and the health services sector; the majority of studies have failed to examine the potential role for the Court in public health policy. Observers such as Greer have seen the development of healthcare as a clear case of neofunctional spillover, a view supported but qualified by Wasserfallen and others, who present a more detailed account of the mechanics of the process. Alternative analyses have focused upon the new modes of governance, soft law and other factors – this article reviews the current state of research in the field and the extent to which it should concern health policy actors and non-specialists in EU policy alike. It concludes that the Court has played and continues to play a crucial role in the development of EU public health policy, as well as in health services and broader social policy, where its influence has already been well documented.

A framework for the evaluation of new interventional procedures - Corrected Proof

Tania Lourenco, Adrian M. Grant, Jennifer M. Burr, Luke Vale — 2011-12-23

Abstract: Objectives: The introduction of new interventional procedures is less regulated than for other health technologies such as pharmaceuticals. Decisions are often taken on evidence of efficacy and short-term safety from small-scale usually observational studies. This reflects the particular challenges of evaluating interventional procedures – the extra facets of skill and training and the difficulty defining a ‘new’ technology. Currently, there is no framework to evaluate new interventional procedures before they become available in clinical practice as opposed to new pharmaceuticals. This paper proposes a framework to guide the evaluation of a new interventional procedure.Proposed framework: A framework was developed consisting of a four-stage progressive evaluation for a new interventional procedure: Stage 1: Development; Stage 2: Efficacy and short-term safety; Stage 3: Effectiveness and cost-effectiveness; and Stage 4: Implementation. The framework also suggests the types of studies or data collection methods that can be used to satisfy each stage.Conclusions: This paper makes a first step on a framework for generating evidence on new interventional procedures. The difficulties and limitations of applying such a framework are discussed.

Exploring industry perspectives on implementation of a provincial policy for food and beverage sales in publicly funded recreation facilities - Corrected Proof

Suzanne Vander Wekken, Susanne Sørensen, John Meldrum, Patti-Jean Naylor — 2011-12-22

Abstract: Objectives: To explore industry perspectives on the transition to healthier food and beverage sales in publicly funded recreation facilities and specifically (a) the awareness of the BC provincial Guidelines and implementation supports; (b) challenges encountered in the transition to healthier products; and (c) thoughts on future trends and opportunities in the snack and beverage business.Methods: We used a qualitative research design (semi-structured interviews) with thematic analysis to explore the data collected.Results: Overall, the industry was aware of the BC Guidelines and philosophically supported the transition to healthier choices in public recreation facilities. Main challenges in implementing the Guidelines were the: (1) perceived limitations of the Guidelines; (2) issues stocking healthy products; (3) competition in food sales environments; and (4) negative impact on profits. Interviewees believed that consumer choice is increasingly influenced by environmental and health priorities and that adapting to these trends would be important for future business success.Conclusions: The food and beverage industry needs time, resources and expertise to adapt their business model and to find new palatable products that meet healthy Guidelines. Strategies that strengthen accountability, provide opportunities for economic development and enhance private–public sector communication will help industry partners support implementation of nutrition policies.

Translation of remuneration arrangements into incentives to delegate to English dental therapists - Corrected Proof

Rebecca V. Harris, Ningwei Sun — 2011-12-19

Abstract: Objectives: To investigate how changes to the dental remuneration system have translated into disincentives to delegate to dental therapists in dental practices.Method: A purposive sample of nine practices was identified incorporating a mix of small, medium and large practices, both with and without dental therapists (DTs). Semi-structured interviews were carried out with 48 principal dentists, associate dentists, DTs, practice managers and dental hygienists. Interview transcripts were analysed using a general inductive approach to identify themes and sub-themes.Results: Four themes were identified: practice finances, productivity, lack of management information relating to the use of DTs, and fairness. DTs were often seen as a ‘cost’ to the team, rather than part of the team as a whole, within a system where contributions were evaluated according to a cost–volume–profit business model. Thus DTs were expected to be ‘self-financing’. The fairness of deducting the salary costs of the DT from associate dentists’ income was an issue.Conclusions: The study reveals that the financial risk sharing model which predominates in dental practice significantly influences how the remuneration system translates into establishing delegation incentives. New organisational forms or a shift in practitioner worldviews of team-working are needed in order for DTs to be fully integrated into dental practice teams.

Eliminating the shortage of registered nurses in Canada: An exercise in applied needs-based planning - Corrected Proof

2011-12-16

Abstract: Objective: To demonstrate the application of a needs-based framework for health human resources (HHR) planning to illustrate the potential effects of policies on the shortage of Registered Nurses (RNs) in Canada.Methods: A simulation model was developed to simultaneously estimate the supply of and requirements for RNs based on data on the health needs of Canadians with current service delivery patterns and levels of productivity as a baseline scenario. The potential individual and cumulative effects of various policy scenarios on the ‘gap’ between these were simulated.Results: A baseline scenario estimated a shortage of about 11,000 RN FTEs in 2007 for Canada, increasing to over 60,000 by 2022. However, multifaceted approaches have the potential to eliminate the estimated shortage.Conclusions: Estimating the requirements for health human resources must explicitly consider population health needs, levels of service delivery and HHR productivity while changing supply to meet requirements involves consideration of a broad range of comprehensive interventions. Investments in improved data collection and planning tools are needed to support more effective HHR planning. The estimated Canadian shortage of RNs based on current circumstances can be resolved in the short to medium tern through modest improvements in RN retention, activity and productivity.

Analysis of the success rates of new drug development in Japan and the lag behind the US - Corrected Proof

2011-12-15

Abstract: Objectives: The launch delay of new drugs has been a major public concern in Japan. Although it is recognized that the delay results from industrial R&D behaviors and regulatory conditions in the global market, the specific mechanisms underlying the significant delay have been unexplained. This study analyzed the association between the success rates of clinical development programs of new molecular entities in Japan and the development lag behind the US and provides clues for policy planning.Methods: The association between the success rates of clinical development and the development time lag between Japan and the US was estimated using the Cox proportional hazard model.Results: The phase II transition success rates in Japan were positively associated with the lags behind US development. Cox regression analysis results of phase III success rates were similar to phase II success rate results but were not statistically significant.Conclusions: The advantageous effect of lags on development success in the latter country (i.e., Japan) appears to explain the persistent delays in development and launch. The government's countermeasures to reduce the access gap of new drugs must consider this mechanism and the influence on both the industry and the target population.

Health workers at the core of the health system: Framework and research issues - Corrected Proof

Sudhir Anand, Till Bärnighausen — 2011-12-12

Abstract: This paper presents a framework for the health system with health workers at the core. We review existing health-system frameworks and the role they assign to health workers. Earlier frameworks either do not include health workers as a central feature of system functioning or treat them as one among several components of equal importance. As every function of the health system is either undertaken by or mediated through the health worker, we place the health worker at the center of the health system.Our framework is useful for structuring research on the health workforce and for identifying health-worker research issues. We describe six research issues on the health workforce: metrics to measure the capacity of a health system to deliver healthcare; the contribution of public- vs. private-sector health workers in meeting healthcare needs and demands; the appropriate size, composition and distribution of the health workforce; approaches to achieving health-worker requirements; the adoption and adaption of treatments by health workers; and the training of health workers for horizontally vs. vertically structured health systems.

Assessing health care planning – A framework-led comparison of Germany and New Zealand - Corrected Proof

Stefanie Ettelt, Mihaly Fazekas, Nicholas Mays, Ellen Nolte — 2011-12-08

Abstract: Objectives: With markets and competition dominating much of the debate on health care reform, health care planning has received little scholarly attention in recent years. Yet in many high-income countries, governments have continued to plan some elements of their health care systems. We use a new framework for analysing health care planning organised around the dimensions of ‘vision’, ‘governance’ and ‘intelligence’ to assess the approach in two deliberately contrasting countries, Germany and New Zealand.Methods: A review of the literature on health care planning in general and specifically in Germany and New Zealand, supported by key participant interviews.Results: Planning in both countries largely reflects the different institutional arrangements of their wider health systems. Planning in Germany is fragmented, in part due to federalism and corporatism, with separate approaches in different health care sectors and regions. In contrast, New Zealand's NHS-style health system favours a more hierarchical, integrated approach, with clear lines of accountability, and central government capacity to define objectives and monitor developments. Both countries find it difficult to use planning to align demand for and supply of health care though New Zealand makes some use of population needs assessments to support this process while these are currently absent in Germany.Conclusions: While it remains challenging to compare health care systems that are institutionally very different, this new framework for analysing their approaches to planning draws attention to their advantages and disadvantages. It also generates an agenda for future research to improve our understanding of the role and effectiveness of different forms of planning versus, and in combination with, other policy tools to relating health care supply and demand.

The Austrian Tobacco Act in practice – Analysing the effectiveness of partial smoking bans in Austrian restaurants and bars - Corrected Proof

Gerhard Reichmann, Margit Sommersguter-Reichmann — 2011-12-06

Abstract: The purpose of this study is to examine the effectiveness of partial smoking bans in restaurants and bars, such as those currently in place in Austria, by evaluating adherence to the relevant regulations and assessing the satisfaction levels of those affected by these regulations.To evaluate adherence, 127 randomly selected restaurants and bars were observed using a form of structured observation. In order to evaluate their level of satisfaction with the regulations, 342 randomly selected customers and 29 restaurant owners were interviewed using standardized questionnaires.The customers widely adhered to the partial smoking bans, but many of them were dissatisfied with the fragmented Austrian solution. Most restaurant owners showed neither adherence to the relevant regulations nor satisfaction with the partial smoking bans. The present study reveals that partial bans on smoking are an ineffective solution. The presumed advantages of these regulations, such as still allowing smoking in restaurants provided a spatial separation of smoking and non-smoking areas is guaranteed, cannot be confirmed; adherence to the partial bans is rather inadequate, especially among restaurant owners, and the level of satisfaction with the Austrian solution is poor as well, not only among smoking and non-smoking customers, but also restaurant owners.

Cancer patient pathways in Denmark as a joint effort between bureaucrats, health professionals and politicians—A national Danish project - Corrected Proof

Helene Bilsted Probst, Zubair Butt Hussain, Ole Andersen — 2011-12-02

Abstract: In 2007 and 2008 Danish Cancer Patient Pathways for 32 cancer types were developed and afterwards implemented on a national scale. Often bureaucrats, health professionals and politicians look upon the health sector in different ways and work independent of each other. In Denmark, as indeed internationally, patient pathways are frequently developed solely by health professionals and the consequence may be major difficulties in implementing the pathways on a national scale. In this article we describe how national Danish Cancer Patient Pathways were developed with a consensus seeking model and the impact it has had on the health system. The model used in Denmark ensured involvement and cooperation between bureaucrats, health professionals and politicians and afterwards a successful national implementation. The Cancer Patient Pathways has significantly reduced waiting times which is thought to increase survival. This experience gives important input to the continuous challenges on how to implement evidence based medicine on a national scale and stipulates a model for this process.

Integrated care for chronic conditions: The contribution of the ICCC Framework - Corrected Proof

Roberto Nuño, Katie Coleman, Rafael Bengoa, Regina Sauto — 2011-11-09

Abstract: Objective: The aim of this research is to highlight the current relevance of the Innovative Care for Chronic Conditions (ICCC) Framework, as a model for change in health systems towards better care for chronic conditions, as well as to assess its impact on health policy development and healthcare redesign to date.Methods: The authors reviewed the literature to identify initiatives designed and implemented following the ICCC Framework. They also reviewed the evidence on the effectiveness, cost-effectiveness and feasibility of the ICCC and the earlier Chronic Care Model (CCM) that inspired it.Results: The ICCC Framework has inspired a wide range of types of intervention and has been applied in a number of countries with diverse healthcare systems and socioeconomic contexts. The available evidence supports the effectiveness of this framework's components, although no study explicitly assessing its comprehensive implementation at a health system level has been found.Conclusions: As awareness of the need to reorient health systems towards better care for chronic patients grows, there is great potential for the ICCC Framework to serve as a road map for transformation, with its special emphasis on integration, and on the role of the community and of a positive political environment.

Restricting unhealthy food sponsorship: Attitudes of the sporting community - Corrected Proof

2011-10-24

Abstract: Objectives: Sponsorship is recognised as a significant marketing tool and restricting unhealthy food sponsorship of children's sport has been recommended by leading health agencies as a contribution towards preventing childhood obesity. This study aimed to determine the junior sporting community's support for policy interventions to restrict unhealthy food sponsorship.Methods: Sports clubs known to have food sponsors and representing the most popular sports for Australian children across a range of demographic areas were recruited. Interview-based questionnaires were conducted at clubs with parents (n=200) and officials (n=20), and with governing sporting associations (n=20). Questionnaires measured respondents’ attitudes towards sponsorship and support for sponsorship regulations.Results: Many officials and parents perceived children to be ‘very’ influenced by elite sport sponsorship (65% of association officials, 53% of parents and 45% of club officials). Children were thought to be less influenced by sponsorship of their own sporting clubs (10%, 11% and 10%, respectively). However, 50% of officials and 70% of parents supported restrictions to children's sport sponsorship. Respondents were most supportive of restricting the use of unhealthy food logos on children's uniforms.Conclusions: Restricting unhealthy food sponsorship is supported by the sporting community and policy change is needed to reduce the perceived impact of this marketing. Alternative funding mechanisms have the potential to maintain sport funding whist reducing promotional opportunities for unhealthy food.

The working status of Japanese female physicians by area of practice: Cohort analysis of taking leave, returning to work, and changing specialties from 1984 to 2004 - Corrected Proof

2011-09-12

Abstract: Background: The percentage of females in the physician workforce is increasing in Japan, as in other countries; however, the working status of female physicians has not been sufficiently investigated.Methods: Original data were obtained from the National Survey of Physicians (NSP) conducted by the Ministry of Health, Labour and Welfare, Japan, from 1984 to 2004. We examined the trend of female physicians’ areas of practice and analyzed their leave, return to work, and change in areas of practice using cohort data.Results: The percentage of female physicians has increased significantly in recent generations, especially in surgery, surgical subareas of practice, and obstetrics and gynecology. A remarkable increase was found in obstetrics and gynecology among women under 29 years old from 15.4 to 66.2%. The total number of female physicians on leave has been higher than the number of female physicians returning since 1998. The average percentage of those who changed their area of practice was high in surgery (20.7%) and low in pediatrics (5.0%) and obstetrics and gynecology (1.7%).Conclusions: A strategic plan is needed for future health policy to plan for the physician workforce, especially for the areas of practice with increasing proportions of young female physicians.