Factors associated with medical consumable availability in level 1 facilities in Malawi: a secondary analysis of a facility census.

BACKGROUND: Medical consumable stock-outs negatively affect health outcomes not only by impeding or delaying the effective delivery of services but also by discouraging patients from seeking care. Consequently, supply chain strengthening is being adopted as a key component of national health strategies. However, evidence on the factors associated with increased consumable availability is limited. METHODS: In this study, we used the 2018-19 Harmonised Health Facility Assessment data from Malawi to identify the factors associated with the availability of consumables in level 1 facilities, ie, rural hospitals or health centres with a small number of beds and a sparsely equipped operating room for minor procedures. We estimate a multilevel logistic regression model with a binary outcome variable representing consumable availability (of 130 consumables across 940 facilities) and explanatory variables chosen based on current evidence. Further subgroup analyses are carried out to assess the presence of effect modification by level of care, facility ownership, and a categorisation of consumables by public health or disease programme, Malawi's Essential Medicine List classification, whether the consumable is a drug or not, and level of average national availability. FINDINGS: Our results suggest that the following characteristics had a positive association with consumable availability-level 1b facilities or community hospitals had 64% (odds ratio [OR] 1·64, 95% CI 1·37-1·97) higher odds of consumable availability than level 1a facilities or health centres, Christian Health Association of Malawi and private-for-profit ownership had 63% (1·63, 1·40-1·89) and 49% (1·49, 1·24-1·80) higher odds respectively than government-owned facilities, the availability of a computer had 46% (1·46, 1·32-1·62) higher odds than in its absence, pharmacists managing drug orders had 85% (1·85, 1·40-2·44) higher odds than a drug store clerk, proximity to the corresponding regional administrative office (facilities greater than 75 km away had 21% lower odds [0·79, 0·63-0·98] than facilities within 10 km of the district health office), and having three drug order fulfilments in the 3 months before the survey had 14% (1·14, 1·02-1·27) higher odds than one fulfilment in 3 months. Further, consumables categorised as vital in Malawi's Essential Medicine List performed considerably better with 235% (OR 3·35, 95% CI 1·60-7·05) higher odds than other essential or non-essential consumables and drugs performed worse with 79% (0·21, 0·08-0·51) lower odds than other medical consumables in terms of availability across facilities. INTERPRETATION: Our results provide evidence on the areas of intervention with potential to improve consumable availability. Further exploration of the health and resource consequences of the strategies discussed will be useful in guiding investments into supply chain strengthening. FUNDING: UK Research and Innovation as part of the Global Challenges Research Fund (Thanzi La Onse; reference MR/P028004/1), the Wellcome Trust (Thanzi La Mawa; reference 223120/Z/21/Z), the UK Medical Research Council, the UK Department for International Development, and the EU (reference MR/R015600/1).

The long-run effects of diagnosis related group payment on hospital lengths of stay in a publicly funded health care system: Evidence from 15 years of micro data.

Diagnosis Related Group (DRG) payment systems are a common means of paying for hospital services. They reward greater activity and therefore potentially encourage more rapid treatment. This paper uses 15 years of administrative data to examine the impact of a DRG system introduced in England on hospital lengths of stay. We utilize different econometric models, exploiting within and cross jurisdiction variation, to identify policy effects, finding that the reduction of lengths of stay was greater than previously estimated and grew over time. This constitutes new and important evidence of the ability of financing reform to generate substantial and persistent change in healthcare delivery.

The sensitivity of hospital coding to prices: evidence from Indonesia.

This study examines a newly introduced DRG system in Indonesia. We use secondary data for 2015 and 2017 from Jaminan Kesehatan Nasional (JKN), a patient level dataset for Indonesia created in 2014 to record public and private hospitals' claims to the national health insurance system to investigate whether there is an association between changes in tariffs paid and the severity of inpatient activity recorded in hospitals. We find a consistent small, positive and statistically significant correlation between changes in tariffs and changes in concentration of activity, indicating discretionary but limited coding behaviour by hospitals. The results indicate that reducing price differentials may mitigate discretionary coding, but that the benefits of this are limited and need to be compared to the potential risk of having to rebase all prices upwards.

Effects of provider incentives on dental X-raying in NHS Scotland: what happens if patients switch providers?

BACKGROUND: In many market settings individuals are encouraged to switch health care providers as a means of ensuring more competition. Switching may have a potentially undesirable side effect of increasing unnecessary treatment. Focusing on the most common source of medical radiation (dental X-rays), the purpose of this study was to assess whether, upon switching dentist, X-ray exposure increases depending on the type of provider payment. METHODS: The analysis used longitudinal data from 2005 to 2016 covering a 5% random sample of the Scottish adult population covered by the National Health Service (NHS). Multiple fixed-effects panel regression analyses were employed to determine the correlation of provider remuneration with patients' likelihood of receiving an X-ray upon switching to a new dentist other things equal. A broad set of covariates including a patient's copayment status was controlled for. RESULTS: Upon switching to a dentist who was paid fee-for-service, patients had a by 9.6%-points (95% CI 7.4-11.8%) higher probability of receiving an X-ray, compared to switching to a salaried dentist. Results were robust when accounting for patient exemption status, as well as unobserved patient and dentist characteristics. CONCLUSIONS: In comparison to staying with the same dentist, patients may be exposed to substantially more X-rays upon switching to a dentist who is paid fee-for-service. There may need to be better guidance and regulation to protect the health of those who have to switch provider due to moving and greater caution in advocating voluntary switching.

Faith-based provision of sexual and reproductive healthcare in Malawi.

Faith-based organisations constitute the second largest healthcare providers in Sub-Saharan Africa but their religious values might be in conflict with providing some sexual and reproductive health services. We undertake regression analysis on data detailing client-provider interactions from a facility census in Malawi and examine whether religious ownership of facilities is associated with the degree of adherence to family planning guidelines. We find that faith-based organisations offer fewer services related to the investigation and prevention of sexually transmitted infections (STIs) and the promotion of condom use. The estimates are robust to several sensitivity checks on the impact of client selection. Given the prevalence of faith-based facilities in Sub-Saharan Africa, our results suggest that populations across the region may be at risk from inadequate sexual and reproductive healthcare provision which could exacerbate the incidence of STIs, such as HIV/AIDS, and unplanned pregnancies.

The impact of moving to a 12h shift pattern on employee wellbeing: A qualitative study in an acute mental health setting.

BACKGROUND: Against a backdrop of increasing demand for mental health services, and difficulties in recruitment and retention of mental health staff, employers may consider implementation of 12 h shifts to reduce wage costs. Mixed evidence regarding the impact of 12 h shifts may arise because research is conducted in divergent contexts. Much existing research is cross sectional in design and evaluates impact during the honeymoon phase of implementation. Previous research has not examined the impact of 12 h shifts in mental health service settings. OBJECTIVE: To evaluate how employees in acute mental health settings adapt and respond to a new 12 h shift system from a wellbeing perspective. DESIGN: A qualitative approach was adopted to enable analysis of subjective employee experiences of changes to organisation contextual features arising from the shift pattern change, and to explore how this shapes wellbeing. SETTING(S): Six acute mental health wards in the same geographical area of a large mental health care provider within the National Health Service in England. PARTICIPANTS: 70 participants including modern matrons, ward managers, clinical leads, staff nurses and healthcare assistants. METHODS: Semi-structured interviews with 35 participants at 6 months post-implementation of a new 12 h shift pattern, with a further 35 interviewed at 12 months post-implementation. RESULTS: Thematic analysis identified unintended consequences of 12 h shifts as these patterns changed roles and the delivery of care, diminishing perceptions of quality of patient care, opportunities for social support, with reports of pacing work to preserve emotional and physical stamina. These features were moderated by older age, commitment to the public healthcare sector, and fit to individual circumstances in the non-work domain leading to divergent work-life balance outcomes. CONCLUSIONS: Findings indicate potential exists for differential wellbeing outcomes of a 12 h shift pattern and negative effects are exacerbated in a stressful and dynamic acute mental health ward context. In a tight labour market with an ageing workforce, employee flexibility and choice are key to retention and wellbeing. Compulsory 12 h shift patterns should be avoided in this setting.

The impact of extending nurse working hours on staff sickness absence: Evidence from a large mental health hospital in England.

BACKGROUND: A pressing international concern is the issue of mental health workforce capacity, which is also of concern in England where staff attrition rates are significantly higher than in physical health services. Increasing demand for mental health services has led to severe financial pressures resulting in staff shortages, increased workloads, and work-related stress, with health care providers testing new models of care to reduce cost. Previous evidence suggests shift work can negatively affect health and wellbeing (increased accidents, fatigue, absenteeism) but can be perceived as beneficial by both employers and employees (fewer handovers, less overtime, cost savings). OBJECTIVE: This study reports an evaluation of the impact of extending the shifts of nurses and health care assistants from 8 to 12 hours. Using data before and after the policy change, the effect of extended working hours on short term sickness (< 7 days) on staff is examined. SETTING: The setting is six inpatient wards within a large mental health hospital in England where the shift extension took place between June and October 2017. The Data come from wards administrative records and the analysis is performed using weekly data (N=463). METHODS: Causal inference methods (Interrupted Time Series and Difference-in-Difference) are used to compare staff sickness rates before and after the implementation, where the outcome variable is defined as the ratio of total sickness hours over the total scheduled working hours (full time equivalents) in a given week. Patient casemix, staff demographics, ward and time variables are included as controls. RESULTS: Estimation results establish that the extended shifts are associated with an increased percentage of sickness hours per week of between 0.73% and 0.98%, the equivalent of a complete shift per week per ward. CONCLUSION: This is the first study to use causal inference to measure the impact of longer shifts on sickness absences for mental health workforce. The analysis is relevant to other providers which may increasingly look towards these shift patterns as a means of cost saving.

Measuring the Activity of Mental Health Services in England: Variation in Categorising Activity for Payment Purposes.

In the context of international interest in reforming mental health payment systems, national policy in England has sought to move towards an episodic funding approach. Patients are categorised into care clusters, and providers will be paid for episodes of care for patients within each cluster. For the payment system to work, clusters need to be appropriately homogenous in terms of financial resource use. We examine variation in costs and activity within clusters and across health care providers. We find that the large variation between providers with respect to costs within clusters mean that a cluster-based episodic payment system would have substantially different financial impacts across providers.

Can productivity growth measures identify best performing hospitals? Evidence from the English National Health Service.

Health-care systems around the world face limited financial resources, and England is no exception. The ability of the health-care system in England to operate within its financial resources depends in part on continually increasing its productivity. One means of achieving this is to identify and disseminate throughout the system the most efficient processes. We examine the annual productivity growth achieved by 151 hospitals over five financial years, using the same methods developed to measure productivity of the National Health Service as a whole. We consider whether there are hospitals that consistently achieve higher than average productivity growth. These could act as examples of good practice for others to follow and provide a means of increasing system performance. We find that the productivity growth of some hospitals over the whole period exhibits better than average performance, but there is little or no evidence of consistency in the performance of these hospitals over adjacent years. Even the best performers exhibit periods of very poor performance and vice versa. We therefore conclude that accepted methods of measuring productivity growth for the health system as a whole do not appear suitable for identifying good performance at the hospital level.

Prospective payment systems and discretionary coding-Evidence from English mental health providers.

Reimbursement of English mental health hospitals is moving away from block contracts and towards activity and outcome-based payments. Under the new model, patients are categorised into 20 groups with similar levels of need, called clusters, to which prices may be assigned prospectively. Clinicians, who make clustering decisions, have substantial discretion and can, in principle, directly influence the level of reimbursement the hospital receives. This may create incentives for upcoding. Clinicians are supported in their allocation decision by a clinical clustering algorithm, the Mental Health Clustering Tool, which provides an external reference against which clustering behaviour can be benchmarked. The aims of this study are to investigate the degree of mismatch between predicted and actual clustering and to test whether there are systematic differences amongst providers in their clustering behaviour. We use administrative data for all mental health patients in England who were clustered for the first time during the financial year 2014/15 and estimate multinomial multilevel models of over, under, or matching clustering. Results suggest that hospitals vary systematically in their probability of mismatch but this variation is not consistently associated with observed hospital characteristics.

Funding approaches for mental health services: Is there still a role for clustering?

Funding for mental health services in England faces many challenges including operating under financial constraints where it is not easy to demonstrate the link between activity and funding. Mental health services need to operate alongside and collaborate with acute hospital services where there is a well-established system for paying for activity. The funding landscape is shifting at a rapid pace and we outline the distinctions between the three main options - block contracts, episodic payment and capitation. Classification of treatment episodes via clustering presents an opportunity to demonstrate activity and reward it within these payment approaches. We have been engaged in research to assess how well the clustering system is performing against a number of fundamental criteria. Clusters need to be reliably recorded, to correspond to health needs, and to treatments that require roughly similar resources. We find that according to these criteria, clusters are falling short of providing a sound basis for measuring and financing services. Yet, we argue, it is the best available option and is essential for a more transparent funding approach for mental health to demonstrate its claim on resources, and that, as such, clusters should be a starting point for evolving a better funding system.

How do time trends in inhospital mortality compare? A retrospective study of England and Scotland over 17 years using administrative data.

OBJECTIVES: To examine the trends in inhospital mortality for England and Scotland over a 17-year period to determine whether and if so to what extent the time trends differ after controlling for differences in the patients treated. DESIGN: Analysis of retrospective administrative hospital data using descriptive aggregate statistics of trends in inhospital mortality and estimates of a logistic regression model of individual patient-level inhospital mortality accounting for patient characteristics, case-mix, and country-specific and year-specific intercepts. SETTING: Secondary care across all hospitals in England and Scotland from 1997 to 2013. POPULATION: Over 190 million inpatient admissions, either electively or emergency, in England or Scotland from 1997 to 2013. DATA: Hospital Episode Statistics for England and the Scottish Morbidity Record 01 for Scotland. MAIN OUTCOME MEASURES: Separately for two admission pathways (elective and emergency), we examine aggregate time trends of the proportion of patients who die in hospital and a binary variable indicating whether an individual patient died in hospital or survived, and how that indicator is influenced by the patient's characteristics, the year and the country (England or Scotland) in which they were admitted. RESULTS: Inhospital mortality has declined in both countries over the period studied, for both elective and emergency admissions, but has declined more in England than Scotland. The difference in trend reduction is greater for elective admissions. These differences persist after controlling for patient characteristics and case-mix. CONCLUSIONS: Comparing data at country level suggests questions about the roles performed by or functioning of their healthcare systems. We found substantial differences between Scotland and England in regard to the trend reductions in inhospital mortality. Hospital resources are therefore being deployed increasingly differently over time in these two countries for reasons that have yet to be explained.

First do no harm - The impact of financial incentives on dental X-rays.

This article assesses the impact of dentist remuneration on the incidence of potentially harmful dental X-rays. We use unique panel data which provide details of 1.3 million treatment claims by Scottish NHS dentists made between 1998 and 2007. Controlling for unobserved heterogeneity of both patients and dentists we estimate a series of fixed-effects models that are informed by a theoretical model of X-ray delivery and identify the effects on dental X-raying of dentists moving from a fixed salary to fee-for-service and patients moving from co-payment to exemption. We establish that there are significant increases in X-rays when dentists receive fee-for-service rather than salary payments and when patients are made exempt from payment.

Getting the right balance? A mixed logit analysis of the relationship between UK training doctors' characteristics and their specialties using the 2013 National Training Survey.

OBJECTIVE: To analyse how training doctors' demographic and socioeconomic characteristics vary according to the specialty that they are training for. DESIGN: Descriptive statistics and mixed logistic regression analysis of cross-sectional survey data to quantify evidence of systematic relationships between doctors' characteristics and their specialty. SETTING: Doctors in training in the United Kingdom in 2013. PARTICIPANTS: 27 530 doctors in training but not in their foundation year who responded to the National Training Survey 2013. MAIN OUTCOME MEASURES: Mixed logit regression estimates and the corresponding odds ratios (calculated separately for all doctors in training and a subsample comprising those educated in the UK), relating gender, age, ethnicity, place of studies, socioeconomic background and parental education to the probability of training for a particular specialty. RESULTS: Being female and being white British increase the chances of being in general practice with respect to any other specialty, while coming from a better-off socioeconomic background and having parents with tertiary education have the opposite effect. Mixed results are found for age and place of studies. For example, the difference between men and women is greatest for surgical specialties for which a man is 12.121 times more likely to be training to a surgical specialty (relative to general practice) than a woman (p-value<0.01). Doctors who attended an independent school which is proxy for doctor's socioeconomic background are 1.789 and 1.413 times more likely to be training for surgical or medical specialties (relative to general practice) than those who attended a state school (p-value<0.01). CONCLUSIONS: There are systematic and substantial differences between specialties in respect of training doctors' gender, ethnicity, age and socioeconomic background. The persistent underrepresentation in some specialties of women, minority ethnic groups and of those coming from disadvantaged backgrounds will impact on the representativeness of the profession into the future. Further research is needed to understand how the processes of selection and the self-selection of applicants into specialties gives rise to these observed differences.

End-Of-Life Medical Spending In Last Twelve Months Of Life Is Lower Than Previously Reported.

Although end-of-life medical spending is often viewed as a major component of aggregate medical expenditure, accurate measures of this type of medical spending are scarce. We used detailed health care data for the period 2009-11 from Denmark, England, France, Germany, Japan, the Netherlands, Taiwan, the United States, and the Canadian province of Quebec to measure the composition and magnitude of medical spending in the three years before death. In all nine countries, medical spending at the end of life was high relative to spending at other ages. Spending during the last twelve months of life made up a modest share of aggregate spending, ranging from 8.5 percent in the United States to 11.2 percent in Taiwan, but spending in the last three calendar years of life reached 24.5 percent in Taiwan. This suggests that high aggregate medical spending is due not to last-ditch efforts to save lives but to spending on people with chronic conditions, which are associated with shorter life expectancies.

Policies towards hospital and GP competition in five European countries.

This study provides an overview of policies affecting competition amongst hospitals and GPs in five European countries: France, Germany, Netherlands, Norway and Portugal. Drawing on the policies and empirical evidence described in five case studies, we find both similarities and differences in the approaches adopted. Constraints on patients' choices of provider have been relaxed but countries differ in the amount and type of information that is provided in the public domain. Hospitals are increasingly paid via fixed prices per patient to encourage them to compete on quality but prices are set in different ways across countries. They can be collectively negotiated, determined by the political process, negotiated between insurers and providers or centrally determined by provider costs. Competition amongst GPs varies across countries and is limited in some cases by shortages of providers or restrictions on entry. There are varied and innovative examples of selective contracting for patients with chronic conditions aimed at reducing fragmentation of care. Competition authorities do generally have jurisdiction over mergers of private hospitals but assessing the potential impact of mergers on quality remains a key challenge. Overall, this study highlights a rich diversity of approaches towards competition policy in healthcare.

Integrating funds for health and social care: an evidence review.

OBJECTIVES: Integrated funds for health and social care are one possible way of improving care for people with complex care requirements. If integrated funds facilitate coordinated care, this could support improvements in patient experience, and health and social care outcomes, reduce avoidable hospital admissions and delayed discharges, and so reduce costs. In this article, we examine whether this potential has been realized in practice. METHODS: We propose a framework based on agency theory for understanding the role that integrated funding can play in promoting coordinated care, and review the evidence to see whether the expected effects are realized in practice. We searched eight electronic databases and relevant websites, and checked reference lists of reviews and empirical studies. We extracted data on the types of funding integration used by schemes, their benefits and costs (including unintended effects), and the barriers to implementation. We interpreted our findings with reference to our framework. RESULTS: The review included 38 schemes from eight countries. Most of the randomized evidence came from Australia, with nonrandomized comparative evidence available from Australia, Canada, England, Sweden and the US. None of the comparative evidence isolated the effect of integrated funding; instead, studies assessed the effects of 'integrated financing plus integrated care' (i.e. 'integration') relative to usual care. Most schemes (24/38) assessed health outcomes, of which over half found no significant impact on health. The impact of integration on secondary care costs or use was assessed in 34 schemes. In 11 schemes, integration had no significant effect on secondary care costs or utilisation. Only three schemes reported significantly lower secondary care use compared with usual care. In the remaining 19 schemes, the evidence was mixed or unclear. Some schemes achieved short-term reductions in delayed discharges, but there was anecdotal evidence of unintended consequences such as premature hospital discharge and heightened risk of readmission. No scheme achieved a sustained reduction in hospital use. The primary barrier was the difficulty of implementing financial integration, despite the existence of statutory and regulatory support. Even where funds were successfully pooled, budget holders' control over access to services remained limited. Barriers in the form of differences in performance frameworks, priorities and governance were prominent amongst the UK schemes, whereas difficulties in linking different information systems were more widespread. Despite these barriers, many schemes - including those that failed to improve health or reduce costs - reported that access to care had improved. Some of these schemes revealed substantial levels of unmet need and so total costs increased. CONCLUSIONS: It is often assumed in policy that integrating funding will promote integrated care, and lead to better health outcomes and lower costs. Both our agency theory-based framework and the evidence indicate that the link is likely to be weak. Integrated care may uncover unmet need. Resolving this can benefit both individuals and society, but total care costs are likely to rise. Provided that integration delivers improvements in quality of life, even with additional costs, it may, nonetheless, offer value for money.

Provider payment bares teeth: dentist reimbursement and the use of check-up examinations.

Oral diseases are one of the most common diseases globally, yet maximizing health benefits from available resources continues to be a pivotal challenge. Similar to recall appointments in many other medical settings, dental check-up examinations are an essential element of regular treatment. Check-ups are important for ensuring good health but their frequent consumption also implies substantial aggregate health care costs. Although it is crucial to determine appropriate utilization amounts, little is known about the role of financial incentives for both patient and provider. Our analyses relied on ten-year administrative panel data from the Scottish National Health Service including about 1.3 million dental treatment claims which were issued between January 1998 and September 2007. Controlling for unobserved heterogeneity, we estimated a series of fixed-effects models to identify the impact of changes in provider payment and patients' cost sharing on check-up utilization. A significantly higher utilization of examinations was observed if dentists were paid fee-for service compared with salary. Comparably little variation in check-up use was attributable to different extents of patient co-payment. These findings establish that different provider payment methods have a substantial impact on check-up utilization. Because recall appointments in many other medical settings have similar features as dental check-ups, these findings may be relevant for health care decision makers who seek to optimize incentive schemes for all kinds of health care.