Evaluation of lay health workers' needs to effectively support anti-tuberculosis treatment adherence in Malawi.

OBJECTIVE: To identify barriers and facilitators to efforts by lay health workers (LHWs) to support anti-tuberculosis treatment adherence in Malawi to inform the design of a knowledge translation intervention for improving adherence. DESIGN: Qualitative study utilizing focus groups and interviews conducted with LHWs providing tuberculosis (TB) care in Zomba District, Malawi. RESULTS: Participants identified lack of knowledge, both general (understanding of TB and its treatment) and job-specific (understanding of tasks such as completion of treatment forms), as the key barrier to LHWs in their role as adherence supporters. Lack of knowledge among LHWs providing TB care was reported to lead to a lack of confidence, conflicting messages given to patients, poor interactions with patients and errors in documentation. In addition to lack of knowledge, a number of system barriers were identified as limiting LHWs' ability to function optimally, including a lack of physical resources, workload, communication delays and ineffective guardians. CONCLUSION: Our findings suggest a gap between LHW knowledge and their responsibilities as adherence supporters. The results have informed the development of an educational outreach intervention and point-of-care tool, to be evaluated in a randomized trial in Zomba District.

Factors affecting the utilization of systematic reviews. A study of public health decision makers.

OBJECTIVE: To determine the extent to which public health decision makers used five systematic reviews to make policy decisions, and to determine which characteristics predict their use. METHODS: This cross-sectional follow-up study of public health decision makers in Ontario collected primary data using a telephone survey and a short, self-administered organizational demographics questionnaire completed by the administrative assistant for each Medical Officer of Health. Independent variables included characteristics of the innovation, organization, environment, and individual. Data were entered into a computerized database developed specifically for this study, and multiple logistic regression analysis was conducted. RESULTS: The participation rate was very high, with 85% of public health units and 96% of available decision makers completing the survey. In addition, 63% of respondents stated they had used at least one of the systematic reviews in the previous 2 years to make a decision. The most important predictors of use were one's position, expecting to use a review in the future, and perceptions that the reviews were easy to use and that they overcame the barrier of limited critical appraisal skills. CONCLUSIONS: Utilization of the systematic reviews in Ontario was very high. The utilization rates found in this study were significantly higher than those reported in previous utilization studies. One's position was found to be the strongest predictor of use, identifying program managers and directors as the most appropriate audience for systematic reviews.

Factors of the innovation, organization, environment, and individual that predict the influence five systematic reviews had on public health decisions.

OBJECTIVE: To determine the extent to which systematic reviews of public health interventions influenced public health decisions and which factors were associated with influencing these decisions. METHODS: This cross-sectional follow-up survey evaluated the use of five systematic reviews in public health decision making. Independent variables included characteristics of the innovation, organization, environment, and individual. Primary data were collected using a telephone survey and a self-administered organizational demographics questionnaire. Public health decision makers in all 41 public health units in Ontario were invited to participate in the study. Multiple linear regression analyses on the five program decisions were conducted. RESULTS: The systematic reviews were perceived as having the greatest amount of influence on decisions related to program justification and program planning, and the least influence on program evaluation decisions. The greater the perception that one's organization valued the use of research evidence for decision making and that ongoing training in the critical appraisal of research literature was provided, the greater the perception of the influence the systematic review had on public health decisions. CONCLUSIONS: Organizational characteristics are important predictors of the use of systematic reviews in public health decision making. Future dissemination strategies need to promote the value of using systematic reviews for program decision making as well as promote ongoing training in critical appraisal among intended users in Ontario.

The effects of fee bundling on dental utilization.

OBJECTIVE: To examine dental utilization following an adjustment to the provincial fee schedule in which preventive maintenance (recall) services were bundled at lower fees. DATA SOURCES/STUDY SETTING: Blue Cross dental insurance claims for claimants associated with four major Ontario employers using a common insurance plan over the period 1987-1990. STUDY DESIGN: This before-and-after design analyzes the dental claims experience over a four-year period for 4,455 individuals 18 years of age and older one year prior to the bundling of services, one year concurrent with the change, and two years after the introduction of bundling. The dependent variable is the annual adjusted payment per user. DATA COLLECTION/EXTRACTION METHODS: The analysis was based on all claims submitted by adult users for services received at recall visits and who reported at least one visit of this type between 1987 and 1990. In these data, 26,177 services were provided by 1,214 dentists and represent 41 percent of all adult service claims submitted over the four years of observation. PRINCIPAL FINDINGS: Real per capita payment for adult recall services decreased by 0.3 percent in the year bundling was implemented (1988), but by the end of the study period such payments had increased 4.8 percent relative to pre-bundling levels. Multiple regression analysis assessed the role of patient and provider variables in the upward trend of per capita payments. The following variables were significant in explaining 37 percent of the variation in utilization over the period of observation: subscriber employment location; ever having received periodontal scaling or ever having received restorative services; regular user; dentist's school of graduation; and interactions involving year, service type, and regular user status. CONCLUSIONS: The volume and intensity of services received by adult patients increased when fee constraints were imposed on dentists. Future efforts to contain dental expenditures through fee schedule design will need to take this into consideration. Issues for future dental services research include provider billing practices, utilization among frequent attenders, and outcomes evaluation particularly with regard to periodontal care and replacement of restorations.

Gender and income in pharmacy: human capital and gender stratification theories revisited.

This is a case study of gender and earnings in pharmacy--a profession characterized by its rapid recruitment of female practitioners. We try to account for disparities in earnings between male and female pharmacists in Ontario with the aid of human capital theory and gender stratification theory. Data is drawn from a random sample of 463 Ontario pharmacists. We find a consistent sex gap in earnings regardless of occupational level of practitioners (i.e. owner, manager or employee) and net of such factors as hours worked, commitment to work, hours devoted to childcare, absences from the labour market, and years since graduation. Instead, the main reason why women in pharmacy earn less than males is because they remain employees throughout their careers. However, we are less successful at identifying the additional factors responsible for the depressed earnings of female practitioners. We discuss our findings in light of the claims of gender stratification and human capital theory.

A conceptual framework for the analysis of health care organizations' performance.

Organizational performance remains an elusive concept despite its importance to health care organizations' (HCOs') management and analysis. This paper uses Parsons' social system action theory to develop a comprehensive theoretically grounded framework by which to overcome the current fragmented approach to HCO performance management. The Parsonian perspective focuses on four fundamental functions that an HCO needs to ensure its survival. Organizational performance is determined by the dynamic equilibrium resulting from the continual interaction of, and interchange among, these four functions. The alignment interchanges allow the creation of bridges between traditional models of organizational performance that are usually used as independent and competing models. The attraction of the Parsonian model lies in its capacity to: (1) embody the various dominant models of organizational performance; (2) present a strong integrative framework in which the complementarity of various HCO performance perspectives are well integrated while their specificity is still well preserved; and (3) enrich the performance concept by making visible several dimensions of HCO performance that are usually neglected. A secondary objective of this paper is to lay the foundation for an integrative process of arbitration among competing indicators and perspectives which is absolutely necessary to make operational the Parsonian model of HCO performance. In this matter, we make reference to the theory of communicative action elaborated by Habermas. It offers, we think, a challenging and refreshing perspective on how to manage HCO performance evaluation processes.

A review of organizational performance assessment in health care.

As health care organizations look for ways to ensure cost-effective, high quality service delivery while still meeting patient needs, organizational performance assessment (OPA) is useful in focusing improvement efforts. In addition, organizational performance assessment is essential for ongoing management decision-making, operational effectiveness and strategy formulation. In this paper, the roles and impact of OPA models in use in health care are reviewed, and areas of potential abuse, such as myopia, tunnel vision and gaming, are identified. The review shows that most existing OPA models were developed primarily as sources of information for purchasers or consumers, or to enable providers to identify areas for improvement. However, there was little conclusive evidence evaluating their impact. This review of existing OPA models enabled the establishment of principles for the development, implementation and prevention of abuse of OPA specific to health care. The OPA models currently in use in health care may provide managers with false confidence in their ability to monitor organizational performance. To further enhance the field of OPA, areas for future research are identified.

Innovation theory and its applicability to our understanding of the diffusion of new management practices in health care organizations.

There has been a longstanding interest in understanding how new management practices and organizational structures are diffused through the health care system. This article reviews current literature on innovation and diffusion to provide insight into how new management practices and organizational structures are introduced into the system. Understanding the process may help in accommodating new developments and provide managerial opportunities to take a more active role in encouraging or discouraging their further evolution.

Physicians in health care management: 9. Strategic alliances and relationships between organizations.

Health care organizations must increasingly develop strategic alliances with other groups and organizations. A variety of interorganizational relationships are possible: shared services, joint programs, umbrella organizations, health agency networks and mergers. As governments try to control health care costs, physicians will play an important role in developing and implementing these alliances. They will be expected to advocate on behalf of patients and communities to ensure that these new organizational arrangements facilitate coordinated care.

Careers in health care management, Part 1: Attainment, expectations and aspirations.

The authors conducted a questionnaire survey of health care managers in Canada to learn more about their careers, work experiences and attitudes; and to determine whether their careers differed by such factors as sector of employment, gender, years of experience, education and family status. Major findings include: in teaching and community hospitals, men are more likely to fill chief executive officer (CEO) positions and women tend to be in middle management positions. More men than women in CEO positions reported incomes in the top range ($105,000). Men in CEO and senior management positions are more likely to be married and have children under 16 years of age living at home. Slightly more women than men were clinicians before becoming managers. Most respondents aspired to CEO or senior management positions. Implications for human resources practices are discussed.

Continuous quality improvement in Canadian health care organizations.

A survey of Canadian health care organizations indicates growing interest in the philosophy and methods of continuous quality improvement (CQI). Most organizations are still in the early stages of learning and applying CQI. Although CEOs have been learning about CQI and have been participating in quality councils, they are less involved in using and teaching CQI techniques. Major obstacles reported in developing quality improvement are lack of time, limited resources, lack of training, and pressures to deal with other changes. Only a few organizations question the value of developing quality improvement, and many who have not yet adopted CQI say they intend to do so.

The role of thematic evaluation in program assessment: the case of the Community Clinical Oncology Program.

The evaluation of programs with multiple, and potentially conflicting, goals requires the integration of measures of goal achievement that often are not easily combined. One approach is the development of analytical themes which span the various goals of a particular program. The themes provide a mechanism by which the policy concerns of individuals with varying perspectives can be integrated into the evaluation framework. As well, the themes allow for flexibility in the development of new analysis as the program matures and environments change. This paper describes the application of the thematic approach to the evaluation of a complex, community-oriented cancer research program.