Patient satisfaction and value based purchasing in hospitals, Odisha, India.

Objective: To examine how a general inpatient satisfaction survey functions as a hospital performance measure. Methods: We conducted a mixed-methods pilot study of the Hospital Consumer Assessment of Health Providers and Systems survey in Odisha, India. We divided the study into three steps: cognitive testing of the survey, item testing with exploratory factor analysis and content validity indexing. Cognitive testing involved 50 participants discussing their interpretation of survey items. The survey was then administered to 507 inpatients across five public hospitals in Odisha, followed by exploratory factor analysis. Finally, we interviewed 15 individuals to evaluate the content validity of the survey items. Findings: Cognitive testing revealed that six out of 18 survey questions were not consistently understood within the Odisha inpatient setting, highlighting issues around responsibilities for care. Exploratory factor analysis identified a six-factor structure explaining 66.7% of the variance. Regression models showed that interpersonal care from doctors and nurses had the strongest association with overall satisfaction. An assessment of differential item functioning revealed that patients with a socially marginalized caste reported higher disrespectful care, though this did not translate into differences in reported satisfaction. Content validity indexing suggested that discordance between experiences of disrespectful care and satisfaction ratings might be due to low patient expectations. Conclusion: Using satisfaction ratings without nuanced approaches in value-based purchasing programmes may mask poor-quality interpersonal services, particularly for historically marginalized patients. Surveys should be designed to accurately capture true levels of dissatisfaction, ensuring that patient concerns are not hidden.

Health Care Spending in the United States and Other High-Income Countries.

IMPORTANCE: Health care spending in the United States is a major concern and is higher than in other high-income countries, but there is little evidence that efforts to reform US health care delivery have had a meaningful influence on controlling health care spending and costs. OBJECTIVE: To compare potential drivers of spending, such as structural capacity and utilization, in the United States with those of 10 of the highest-income countries (United Kingdom, Canada, Germany, Australia, Japan, Sweden, France, the Netherlands, Switzerland, and Denmark) to gain insight into what the United States can learn from these nations. EVIDENCE: Analysis of data primarily from 2013-2016 from key international organizations including the Organisation for Economic Co-operation and Development (OECD), comparing underlying differences in structural features, types of health care and social spending, and performance between the United States and 10 high-income countries. When data were not available for a given country or more accurate country-level estimates were available from sources other than the OECD, country-specific data sources were used. FINDINGS: In 2016, the US spent 17.8% of its gross domestic product on health care, and spending in the other countries ranged from 9.6% (Australia) to 12.4% (Switzerland). The proportion of the population with health insurance was 90% in the US, lower than the other countries (range, 99%-100%), and the US had the highest proportion of private health insurance (55.3%). For some determinants of health such as smoking, the US ranked second lowest of the countries (11.4% of the US population ≥15 years smokes daily; mean of all 11 countries, 16.6%), but the US had the highest percentage of adults who were overweight or obese at 70.1% (range for other countries, 23.8%-63.4%; mean of all 11 countries, 55.6%). Life expectancy in the US was the lowest of the 11 countries at 78.8 years (range for other countries, 80.7-83.9 years; mean of all 11 countries, 81.7 years), and infant mortality was the highest (5.8 deaths per 1000 live births in the US; 3.6 per 1000 for all 11 countries). The US did not differ substantially from the other countries in physician workforce (2.6 physicians per 1000; 43% primary care physicians), or nursing workforce (11.1 nurses per 1000). The US had comparable numbers of hospital beds (2.8 per 1000) but higher utilization of magnetic resonance imaging (118 per 1000) and computed tomography (245 per 1000) vs other countries. The US had similar rates of utilization (US discharges per 100 000 were 192 for acute myocardial infarction, 365 for pneumonia, 230 for chronic obstructive pulmonary disease; procedures per 100 000 were 204 for hip replacement, 226 for knee replacement, and 79 for coronary artery bypass graft surgery). Administrative costs of care (activities relating to planning, regulating, and managing health systems and services) accounted for 8% in the US vs a range of 1% to 3% in the other countries. For pharmaceutical costs, spending per capita was $1443 in the US vs a range of $466 to $939 in other countries. Salaries of physicians and nurses were higher in the US; for example, generalist physicians salaries were $218 173 in the US compared with a range of $86 607 to $154 126 in the other countries. CONCLUSIONS AND RELEVANCE: The United States spent approximately twice as much as other high-income countries on medical care, yet utilization rates in the United States were largely similar to those in other nations. Prices of labor and goods, including pharmaceuticals, and administrative costs appeared to be the major drivers of the difference in overall cost between the United States and other high-income countries. As patients, physicians, policy makers, and legislators actively debate the future of the US health system, data such as these are needed to inform policy decisions.

Private pharmacies as healthcare providers in Odisha, India: analysis and implications for universal health coverage.

INTRODUCTION: In India, as in many low-income and middle-income countries, the private sector provides a large share of health care. Pharmacies represent a major share of private care, yet there are few studies on their role as healthcare providers. Our study examines: (1) What are the characteristics of and services provided by private pharmacies and how do these compare with other outpatient care providers? (2) What are the characteristics of patients who opted to use private pharmacies? (3) What are the reasons why people seek healthcare from private pharmacies? (4) What are the quality of services and cost of care for these patients? Based on our findings, we discuss some policy implications for universal health coverage in the Indian context. METHODS: We analyse data from four surveys in Odisha, one of India's poorest states: a household survey on health-seeking behaviours and reasons for healthcare choices (N=7567), a survey of private pharmacies (N=1021), a survey of public sector primary care facilities (N=358), and a survey of private-sector solo-providers (N=684). RESULTS: 17% of the households seek outpatient care from private pharmacies (similar to rates for public primary-care facilities). 25% of the pharmacies were not registered appropriately under Indian regulations, 90% reported providing medical advice, and 26% reported substituting prescribed drugs. Private pharmacies had longer staffed hours and better stocks of essential drugs than public primary-care facilities. Patients reported choosing private pharmacies because of convenience and better drug stocks; reported higher satisfaction and lower out-of-pocket expenditure with private pharmacies than with other providers. CONCLUSION: This is the first large-scale study of private pharmacies in India, with a comparison to other healthcare providers and users' perceptions and experiences of their services. To move towards universal health coverage, India, a country with a pluralistic health system, needs a comprehensive health systems approach that incorporates both the public and private sectors, including private pharmacies.

Comprehensive Assessment of Health System Performance in Odisha, India.

India has recently implemented several major health care reforms at national and state levels, yet the nation continues to face significant challenges in achieving better health system performance. These challenges are particularly daunting in India's poorer states, like Odisha. The first step toward overcoming these challenges is to understand their root causes. Toward this end, the Harvard T.H. Chan School of Public Health conducted a comprehensive study in Odisha based on ten new field surveys of the system's performance to provide a multi-perspective analysis. This article reports on the assessment of the performance of Odisha's health system and the preliminary diagnosis of underlying causes of the strengths and challenges. This comprehensive health system assessment is aimed toward the overarching goals of informing and supporting efforts to improve the performance of health systems in Odisha and other similar contexts.

Early social distancing policies in Europe, changes in mobility & COVID-19 case trajectories: Insights from Spring 2020.

BACKGROUND: Social distancing have been widely used to mitigate community spread of SARS-CoV-2. We sought to quantify the impact of COVID-19 social distancing policies across 27 European counties in spring 2020 on population mobility and the subsequent trajectory of disease. METHODS: We obtained data on national social distancing policies from the Oxford COVID-19 Government Response Tracker and aggregated and anonymized mobility data from Google. We used a pre-post comparison and two linear mixed-effects models to first assess the relationship between implementation of national policies and observed changes in mobility, and then to assess the relationship between changes in mobility and rates of COVID-19 infections in subsequent weeks. RESULTS: Compared to a pre-COVID baseline, Spain saw the largest decrease in aggregate population mobility (~70%), as measured by the time spent away from residence, while Sweden saw the smallest decrease (~20%). The largest declines in mobility were associated with mandatory stay-at-home orders, followed by mandatory workplace closures, school closures, and non-mandatory workplace closures. While mandatory shelter-in-place orders were associated with 16.7% less mobility (95% CI: -23.7% to -9.7%), non-mandatory orders were only associated with an 8.4% decrease (95% CI: -14.9% to -1.8%). Large-gathering bans were associated with the smallest change in mobility compared with other policy types. Changes in mobility were in turn associated with changes in COVID-19 case growth. For example, a 10% decrease in time spent away from places of residence was associated with 11.8% (95% CI: 3.8%, 19.1%) fewer new COVID-19 cases. DISCUSSION: This comprehensive evaluation across Europe suggests that mandatory stay-at-home orders and workplace closures had the largest impacts on population mobility and subsequent COVID-19 cases at the onset of the pandemic. With a better understanding of policies' relative performance, countries can more effectively invest in, and target, early nonpharmacological interventions.

Leveraging massive open online courses to expand quality of healthcare education to health practitioners in Rwanda.

Improving the quality of healthcare delivery is increasingly a global health priority. However, quality improvement training opportunities that provide theoretical foundations and basic skills for patient safety and other quality initiatives have been limited or historically out of reach, especially in low-and-middle income countries (LMICs). To address this gap, the Harvard Initiative on Global Health Quality (HIGHQ) created and launched a massive open online course (MOOC) in 2014 focused on patient safety and quality of care using the edX platform. More than 30 000 students from across 195 countries registered for the online course. This paper summarises an innovative educational partnership between the course team and one of these countries, Rwanda, to develop a blended-learning model to bolster participation in this new course among Rwandan healthcare professionals. Although a small country, Rwanda was among the top performing countries for attracting course registrants and was the leading country for the proportion of enrollees who ultimately completed the course. Further, half (21 of 42) of Rwanda's district hospitals opted to appoint a PH555x course facilitator at their site to help lead regular meetings and discussions about the course content at their facility. The majority of Rwandan enrollees were health professionals (63%) and 81% reported that PH555x was their first experience taking an online course. Among those participating in the 'flipped' component at hospital sites, 94% reported that the course helped them to think of specific ways to improve healthcare quality at their facility. In this paper, we describe this innovative public-private educational model, challenges to implementation and lessons learned that may be helpful for future MOOC developers who wish to augment learning opportunities among healthcare professionals in LMICs.

Performance of UK National Health Service compared with other high income countries: observational study.

OBJECTIVE: To determine how the UK National Health Service (NHS) is performing relative to health systems of other high income countries, given that it is facing sustained financial pressure, increasing levels of demand, and cuts to social care. DESIGN: Observational study using secondary data from key international organisations such as Eurostat and the Organization for Economic Cooperation and Development. SETTING: Healthcare systems of the UK and nine high income comparator countries: Australia, Canada, Denmark, France, Germany, the Netherlands, Sweden, Switzerland, and the US. MAIN OUTCOME MEASURES: 79 indicators across seven domains: population and healthcare coverage, healthcare and social spending, structural capacity, utilisation, access to care, quality of care, and population health. RESULTS: The UK spent the least per capita on healthcare in 2017 compared with all other countries studied (UK $3825 (£2972; €3392); mean $5700), and spending was growing at slightly lower levels (0.02% of gross domestic product in the previous four years, compared with a mean of 0.07%). The UK had the lowest rates of unmet need and among the lowest numbers of doctors and nurses per capita, despite having average levels of utilisation (number of hospital admissions). The UK had slightly below average life expectancy (81.3 years compared with a mean of 81.7) and cancer survival, including breast, cervical, colon, and rectal cancer. Although several health service outcomes were poor, such as postoperative sepsis after abdominal surgery (UK 2454 per 100 000 discharges; mean 2058 per 100 000 discharges), 30 day mortality for acute myocardial infarction (UK 7.1%; mean 5.5%), and ischaemic stroke (UK 9.6%; mean 6.6%), the UK achieved lower than average rates of postoperative deep venous thrombosis after joint surgery and fewer healthcare associated infections. CONCLUSIONS: The NHS showed pockets of good performance, including in health service outcomes, but spending, patient safety, and population health were all below average to average at best. Taken together, these results suggest that if the NHS wants to achieve comparable health outcomes at a time of growing demographic pressure, it may need to spend more to increase the supply of labour and long term care and reduce the declining trend in social spending to match levels of comparator countries.

The Relationship Between Health Spending And Social Spending In High-Income Countries: How Does The US Compare?

There is broad consensus that the US spends too much on health care. One proposed driver of the high US spending is low investment in social services. We examined the relationship between health spending and social spending across high-income countries. We found that US social spending (at 16.1 percent of gross domestic product [GDP] in 2015) is slightly below the average for Organization for Economic Cooperation and Development (OECD) countries (17.0 percent of GDP) and above that average when education spending is included (US: 19.7 percent of GDP; OECD: 17.7 percent of GDP). We found that countries that spent more on social services tended to spend more on health care. Adjusting for poverty and unemployment rates and the proportion of people older than age sixty-five did not meaningfully change these associations. In addition, when we examined changes over time, we found additional evidence for a positive relationship between social and health spending: Countries with the greatest increases in social spending also had larger increases in health care spending.

Quality of care in large Chinese hospitals: an observational study.

OBJECTIVE: To empirically assess the quality of hospital care in China and trends over a 5-year period during which the government significantly increased its investment in healthcare. DESIGN: Retrospective, observational study comparing hospital quality between two periods: October 2012-March 2013 and October 2017-March 2018. SETTING: 1-2 of the most reputable large tertiary hospitals in each of the 25 provinces in Mainland China (total of 33). PARTICIPANTS: Adults 18 years or older admitted with acute myocardial infarction (AMI) (n = 7031), cerebral ischaemic stroke (n = 12 008), chronic obstructive pulmonary disease (COPD) (n = 11 836) and bacterial pneumonia (n = 4263). MAIN OUTCOME MEASURES: Process-based quality measures, including seven AMI measures, three stroke measures, four COPD measures and six pneumonia measures. RESULTS: In 2012/2013, Chinese hospitals had variable performance on AMI measures, including prescribing aspirin on arrival (80.7%), and discharging patients on aspirin (79.2%), ß-blockers (60.8%) or statins (75.8%). This was similar for stroke cases and pneumonia cases. Smoking cessation advice was given at high rates across conditions though rates of influenza/pneumococcal vaccines were performed <1%. In 2017/2018, Chinese hospitals experienced no differences across most quality measures. Performance declined for two measures: aspirin on arrival for AMI cases and blood cultures before antibiotics for pneumonia cases. Performance increased for two measures: percutaneous coronary intervention within 90 min in ST segment elevation myocardial infarction cases (66.6% vs 80.1%, p<0.001) and statins at discharge for stroke cases (64.7% vs 78.7%, p<0.001). Compared with US hospitals, Chinese hospitals underperformed across most measures. CONCLUSIONS: Chinese hospitals had low and variable performances across most quality measures for common medical conditions. Quality of care generally does not appear to be improving post national health reform. The Chinese government should include quality of care improvement in its health reform priorities to ensure patients receive appropriate and effective care.

A comparison of how four countries use health IT to support care for people with chronic conditions.

Countries around the globe are investing in health information and communications technologies (ICTs) as critical tools for improving care for chronically ill patients. We profiled four high-income nations with varied health ICT strategies--Australia, Canada, Denmark, and the United States--to describe their use of ICTs to improve chronic care. Our goal was to identify common challenges and opportunities for cross-national learning. We found four key themes. First, although all four countries have a national strategy for health ICT adoption, strategies are implemented and adapted to chronic care needs regionally, which creates the challenge of spreading successful efforts across regions. Second, each country struggles with how to ensure that clinical information follows patients seamlessly between care settings. Third, although each nation is pursuing telehealth solutions as a component of chronic care, the telehealth initiatives are usually stand-alone efforts that are not well integrated into other ICT solutions, such as electronic health records. Finally, countries have made progress in improving patients' access to their clinical data but have not fully succeeded in engaging patients to apply the data to improve care. These common themes suggest that although the four nations have different health care systems and ICT strategies, all of them face a similar set of challenges, creating an opportunity for cross-national learning.