ABSTRACT
INTRODUCTION: The specialty of emergency medicine is experiencing the convergence of a number of transformational forces in the United States, including health care reform, technological advancements, and societal shifts. These bring both opportunity and uncertainty. 21ST CENTURY CHALLENGES: Persistent challenges such as the opioid epidemic, rising health care costs, misaligned incentives, patients with multiple chronic diseases, and emergency department crowding continue to plague the acute, unscheduled care system. REDUCTIONISM AND COMPLEX SYSTEMS THINKING: The traditional approach to health care practice and improvement-reductionism-is not adequate for the complexity of the twenty-first century. Reductionist thinking will likely continue to produce unintended consequences and suboptimal outcomes. Complex systems thinking provides a perspective and set of tools better suited for the challenges and opportunities facing public health in general, and emergency medicine more specifically. IMPLICATIONS FOR EMERGENCY MEDICINE: This article introduces complex systems thinking and argues for its application in the context of emergency medicine by drawing on the history of the circumstances surrounding the formation of the specialty and by providing examples of its application to several practice challenges.
Subject(s)
Emergency Medicine/organization & administration , Systems Analysis , Organizational Innovation , Uncertainty , United StatesABSTRACT
RATIONALE, AIMS AND OBJECTIVES: The current health system in the United States is the result of a history of patchwork policy decisions and cultural assumptions that have led to persistent contradictions in practice, gaps in coverage, unsustainable costs, and inconsistent outcomes. In working toward a more efficient health system, understanding and applying complexity science concepts will allow for policy that better promotes desired outcomes and minimizes the effects of unintended consequences. METHODS: This paper will consider three applied complexity science concepts in the context of the Patient Protection and Affordable Care Act (PPACA): developing a shared vision around reimbursement for value, creating an environment for emergence through simple rules, and embracing transformational leadership at all levels. RESULTS AND CONCLUSIONS: Transforming the US health system, or any other health system, will be neither easy nor quick. Applying complexity concepts to health reform efforts, however, will facilitate long-term change in all levels, leading to health systems that are more effective, efficient, and equitable.
Subject(s)
Health Care Reform , Patient Protection and Affordable Care Act , Delivery of Health Care/organization & administration , Health Policy , Humans , Leadership , Reimbursement, Incentive , United StatesABSTRACT
OBJECTIVE: To systematically review and analyze various ways that health systems frameworks interact with the social determinants of health (SDH), as well as the implications of these interactions. METHODS: This was a review of the literature conducted in 2012 using predetermined criteria to search three comprehensive databases (PubMed, the Cochrane Database for Systematic Reviews, and the World Bank E-Library) and grey literature for articles with any consideration of the SDH within health systems frameworks. Snowball sampling and expert opinion were used to include any potentially relevant articles not identified by the initial search. In total, 4 152 documents were found; of these, 27 were included in the analyses. RESULTS: Five main categories of interaction between health systems and SDH emerged: Bounded, Production, Reciprocal, Joint, and Systems models. At one end were the Bounded and Production models, which conceive the SDH to be outside the health system; at the other end, the Joint and Systems models, which visualize a continuous and dynamic interaction. CONCLUSIONS: Considering the complex and dynamic interactions among different kinds of organizations involved in and with the health system,the Joint and Systems models seem to best reflect these interactions, and should thereby guide stakeholders in planning for change.
OBJETIVO: Examinar y analizar sistemáticamente las diversas maneras en que los marcos de los sistemas de salud abordan las interacciones con los determinantes sociales de la salud (DSS), así como las implicaciones de estas interacciones. MÉTODOS: En el 2012, se llevó a cabo una revisión de la bibliografía mediante la adopción de criterios predeterminados para consultar tres bases de datos integrales (PubMed, la Base de Datos Cochrane de Revisiones Sistemáticas y la Biblioteca electrónica del Banco Mundial) y la bibliografía gris, en busca de artículos que incluyeran cualquier tipo de consideración de los DSS en los marcos de los sistemas de salud. Se utilizó el muestreo de bola de nieve y la opinión de expertos con objeto de incluir cualquier artículo potencialmente pertinente no detectado en la búsqueda inicial. En total, se encontraron 4 152 documentos; de estos, 27 se incluyeron en el análisis. RESULTADOS: Se observaron cinco categorías o modelos principales de interacción entre los sistemas de salud y los DSS: Vinculado, de Producción, Recíproco, Conjunto y de Sistemas. En un extremo se situaban los modelos Vinculado y de Producción, que contemplan los DSS como externos al sistema de salud; en el otro extremo, los modelos Conjunto y de Sistemas, que conciben una interacción continua y dinámica entre ellos. CONCLUSIONES: Si se tienen en cuentas las complejas y dinámicas interacciones entre los diferentes tipos de organizaciones involucradas en y con el sistema de salud, los modelos Conjunto y de Sistemas parecen reflejar mejor estas interacciones y, en consecuencia, son los que deberían guiar a los interesados directos en la planificación de los cambios.
Subject(s)
Humans , Delivery of Health Care , Health Services/statistics & numerical data , Models, Theoretical , Social Determinants of Health , Systems Integration , Americas , Community-Institutional Relations , Health Care Sector/organization & administration , Health Services Administration , Public Policy , Qualitative Research , Social EnvironmentABSTRACT
OBJECTIVE: To systematically review and analyze various ways that health systems frameworks interact with the social determinants of health (SDH), as well as the implications of these interactions. METHODS: This was a review of the literature conducted in 2012 using predetermined criteria to search three comprehensive databases (PubMed, the Cochrane Database for Systematic Reviews, and the World Bank E-Library) and grey literature for articles with any consideration of the SDH within health systems frameworks. Snowball sampling and expert opinion were used to include any potentially relevant articles not identified by the initial search. In total, 4,152 documents were found; of these, 27 were included in the analyses. RESULTS: Five main categories of interaction between health systems and SDH emerged: Bounded, Production, Reciprocal, Joint, and Systems models. At one end were the Bounded and Production models, which conceive the SDH to be outside the health system; at the other end, the Joint and Systems models, which visualize a continuous and dynamic interaction. CONCLUSIONS: Considering the complex and dynamic interactions among different kinds of organizations involved in and with the health system,the Joint and Systems models seem to best reflect these interactions, and should thereby guide stakeholders in planning for change.
Subject(s)
Delivery of Health Care , Health Services/statistics & numerical data , Models, Theoretical , Social Determinants of Health , Systems Integration , Americas , Community-Institutional Relations , Health Care Sector/organization & administration , Health Services Administration , Humans , Public Policy , Qualitative Research , Social EnvironmentSubject(s)
Public Policy , Guidelines as Topic , Americas , Public Policy , Health Equity , Guidelines as Topic , Americas , Models, Theoretical , Qualitative Research , Social Environment , Health Systems , Delivery of Health Care , Health Services , Social Determinants of Health , Systems Integration , Community-Institutional Relations , Health Care Sector , Health Services AdministrationABSTRACT
While reaching consensus on future plans to address current global health challenges is far from easy, there is broad agreement that reductionist approaches that suggest a limited set of targeted interventions to improve health around the world are inadequate. We argue that a comprehensive systems perspective should guide health practice, education, research and policy. We propose key 'systems thinking' tools and strategies that have the potential for transformational change in health systems. Three overarching themes span these tools and strategies: collaboration across disciplines, sectors and organizations; ongoing, iterative learning; and transformational leadership. The proposed tools and strategies in this paper can be applied, in varying degrees, to every organization within health systems, from families and communities to national ministries of health. While our categorization is necessarily incomplete, this initial effort will provide a valuable contribution to the health systems strengthening debate, as the need for a more systemic, rigorous perspective in health has never been greater.
Subject(s)
Delivery of Health Care/organization & administration , Efficiency, Organizational , Developing Countries , Global Health , Health Education , Health Policy , Health Resources/organization & administration , Health Services Research , Interdisciplinary Communication , Leadership , Learning , Organizational Innovation , ThinkingSubject(s)
Delivery of Health Care/trends , Developed Countries , Developing Countries , Health Services Needs and Demand , International Cooperation , Internationality , Congresses as Topic , Delivery of Health Care/economics , Developing Countries/economics , Goals , Health Systems Agencies , Humans , World Health OrganizationABSTRACT
This study retrospectively analyzed demographic factors that may affect the prevalence of intestinal parasites among Guatemalan school children. The findings of the study showed that young age, wet season, female gender, and severe malnutrition all correlated positively with increased rates of infection. Clinical visits were performed on 10,586 school children aged 5-15 years over a four-year period (2004-2007) in the Palajunoj Valley of Guatemala, during which 5,705 viable stool samples were screened for infection with the following parasites: Ascaris lumbricoides, Giardia lamblia, Entamoeba histolytica, Hymenolepis nana, and Blastocystis hominis. The average overall prevalences of infection for specific parasites were A. lumbricoides 17.7%, E. histolytica 16.1%, G. lamblia 10.9%, H. nana 5.4%, and B. hominis 2.8%. Statistical analysis showed significantly higher rates of infection among younger children with G. lamblia (odds ratio [OR]=0.905, 95% confidence interval [CI] 0.871-0.941, p<0.0001) and E. histolytica (p=0.0006), greater prevalence of H. nana among females (OR=1.275, CI 1.010-1.609, p=0.0412), higher infection rates during the wet season for E. histolytica (p=0.0003) and H. nana (OR=0.734, CI 0.557-0.966, p=0.0275), and greater rates of infection with G. lamblia among malnourished children (for moderately malnourished children OR=1.498, CI 1.143-1.963, p<0.0001) and E. histolytica (for mildly malnourished children OR=1.243, CI 1.062-1.455, p=0.0313). The results suggest that the prevalence of gastrointestinal parasites among young Guatemalan children is highly dependent on the specific species of the parasite.
