Using patient-generated health data in clinical practice: How timing influences its function in rheumatology outpatient consultations.

OBJECTIVE: Utilizing patient-generated health data (PGHD) in clinical consultations and informing clinical and shared decision-making processes has the potential to improve clinical practice but has proven challenging to implement. Looking at consultations between people with rheumatoid arthritis (RA) and rheumatologists, this study examines when and how daily PGHD was discussed in outpatient consultations. METHODS: We conducted a secondary qualitative analysis of 17 audio-recorded research outpatient consultations using thematic and interactional approaches. RESULTS: Clinicians decided when to look at the PGHD and what symptoms to prioritise during the consultation. When PGHD was introduced early in consultations, it was usually used to invite patients to collaborate (elicit new information). When introduced later, PGHD was used to corroborate patient accounts and to convince the patient about proposed actions and treatments. Clinicians occasionally disregarded PGHD if it did not fit into their clinical assessment. CONCLUSION: The time that PGHD is introduced may influence how PGHD is used in consultations. Further research is needed to understand how best to empower patients to discuss PGHD. PRACTICE IMPLICATIONS: Educating patients and clinicians about the importance of timing and strategies when using PGHD in consultations may help promote shared decision-making.

The impact of the Affordable Care Act on patient coverage and access to care: perspectives from FQHC administrators in Arizona, California and Texas.

BACKGROUND: The Affordable Care Act (ACA) enabled millions of people to gain coverage that was expected to improve access to healthcare services. However, it is unclear the extent of the policy's impact on Federally Qualified Health Centers (FQHC) and the patients they served. This study sought to understand FQHC administrators' views on the ACA's impact on their patient population and organization. It specifically explores FQHC administrators' perspective on 1) patients' experience with gaining coverage 2) their ability to meet patients' healthcare needs. METHODS: Twenty-two semi-structured interviews were conducted with administrators from FQHCs in urban counties in 2 Medicaid-expanded states (Arizona and California) and 1 non-expanded state (Texas). An inductive thematic analysis approach was used to analyze the interview data. RESULTS: All FQHC administrators reported uninsured patients were more likely to gain coverage from Medicaid than from private health insurance. Insured patients generally experienced an improvement in accessing healthcare services but depended on their plan's covered services, FQHCs' capacity to meet demand, and specialist providers' willingness to accept their coverage type. CONCLUSION: Gaining coverage helped improved newly insured patients' access to care, but limitations remained. Additional policies are required to better address the gaps in the depth of covered services in Medicaid and the most affordable PHI plans and capacity of providers to meet demand to ensure beneficiaries can fully access the health care services they need.

Analysing the impact of private health insurance on inequities in health care utilization: a longitudinal study from China.

Since the early 2000s, Chinese government has sought to encourage the growth of private health insurance (PHI) while simultaneously expanding the breadth of coverage in its social health insurance (SHI) system. This paper examines how the prevalence of PHI has changed during this period and the extent to which PHI contributed to the growth of horizontal and geographical inequities with a focus on healthcare utilization. National data from China Health and Nutrition Survey between 2000 and 2015 were analysed using a multilevel modelling approach. The analysis investigated the impact of SHI membership as related to PHI uptake, PHI enrolees' utilization of health services and out-of-pocket (OOP) expenses. This study found being covered by an SHI scheme reduced the uptake of PHI between 2004 and 2015. Having PHI caused an increase in utilizing outpatient care but did not affect OOP expenses. Coverage prevalence of PHI in a residential community was positively associated with the average level of healthcare utilization. Coverage prevalence of PHI and its effects on healthcare utilization varied geographically. The findings suggest that expanding the role of PHI was not effective without clear support from government policy. Furthermore, the expansion of PHI may cause an increase in horizontal and geographical inequities in healthcare utilization.

Health insurance enrollment strategies during the Affordable Care Act (ACA): a scoping review on what worked and for whom.

BACKGROUND: The Affordable Care Act (ACA) provided an opportunity for millions of people in the U.S. to get coverage from the publicly funded Medicaid program or private insurance from the newly established marketplace. However, enrolling millions of people for health insurance was an enormous task. The aim of this review was to examine the strategies used to enroll people for health insurance and their effectiveness after implementing the ACA's coverage expansion. METHODS: The PRISMA Extension for Scoping Review (PRISMA-ScR) guided this review. Included studies were empirical studies that met the inclusion criteria and published between 2010 and 2020. Studies were searched mainly from two scholarly databases, CINAHL Plus and Medline (PubMed) using keyword searches. Hand searches from the references of selected journals were also performed. Content analysis was conducted by two authors in which codes were inductively developed to identify themes. RESULTS: There were 2213 potential studies identified from the search, but 10 met the inclusion criteria. The research design of the studies varied. Two studies were randomized trials, one quasi-experimental trial, three mixed-methods, two qualitative and two quantitative. All studies focused on strategies used to inform and help people enroll for either Medicaid or private insurance from the marketplace. This review identified three key strategies used to help enroll people for coverage: 1) individual assistance; 2) community outreach; and 3) health education and promotion (HE&P). CONCLUSION: Community-based organizations were likely to use a combination of the three strategies simultaneously to reach uninsured individuals and directly help them enroll for health insurance. Other organizations that aimed to reach a wider segment of the population used single strategies, such as community outreach or HE&P.

Changing health care with, for, or against the public: an empirical investigation into the place of the public in health service reconfiguration.

OBJECTIVES: This study sought to understand the different approaches taken to involving the public in service reconfiguration in the four United Kingdom health systems. METHODS: This was a multi-method study involving policy document analysis and qualitative semi-structured interviews in England, Northern Ireland, Scotland and Wales. RESULTS: Despite the diversity of local situations, interview participants tended to use three frames within which they understood the politics of service reconfigurations: an adversarial approach which assumed conflict over scarce resources (change against the public); a communications approach which defined the problem as educating the public on the desirability of change (change for the public); and a collaborative approach which attempted to integrate the public early into discussions about the shape and nature of desirable services (change with the public). These three framings involved different levels of managerial time, energy, and resources and called on different skill sets, most notably marketing and communications for the communications approach and community engagement for the collaborative approach. CONCLUSIONS: We argue that these framings of public involvement co-exist within organisations. Health system leaders, in framing service reconfiguration as adversarial, communicative or collaborative, are deciding between conceptions of the relationship between health care organisations and their publics in ways that shape the nature of the debates that follow. Understanding the reasons why organisations adopt these frames would be a fruitful way to advance both theory and practice.

Developing an Intervention to Implement Electronic Patient-Reported Outcomes in Renal Services in the UK.

Routinely collecting and using electronic patient-reported outcome (ePRO) data in clinical practice can improve patients' experience and outcomes, but implementing this at scale has proved challenging. As part of the Optimising routine collection of electronic patient-reported outcomes (OPT-ePRO) study, we therefore developed an intervention that aimed to facilitate the implementation of ePROs. We are conducting OPT-ePRO in the context of secondary care for people with chronic kidney disease in the UK, with three renal units participating as our study sites. Intervention design was guided by Normalisation Process Theory, and informed by published literature and qualitative research. The intervention consisted of a national infrastructure to securely collect, transfer and display ePRO data, complemented with materials and procedures to support kidney patients and renal unit staff with embedding ePROs in usual care pathways. The next step will be to bring the OPT-ePRO intervention into practice and iteratively refine it.

Between a rock and a hard place: Comparing arms' length bodies for public involvement in healthcare across the UK.

Arms' length bodies are often seen as a tool of technocratic governance, designed to insulate decision-making from the politicizing pressures of populist influence. This article examines a subset of arms' length bodies in the UK which challenge this convention: agencies which exist to 'champion' the voice of patients and the public in the four NHS systems (England, Northern Ireland, Scotland and Wales). We compare the functions of these agencies on paper and through qualitative interviews in each system which focused on public involvement in major service change (such as closing hospitals). We found that agencies in all four systems had struggled to demonstrate their legitimacy, squeezed between the demands of the elected Governments they answer to, the NHS organisations they are meant to support and challenge, and the publics whose voices they are meant to amplify. We argue that the evolving solutions found in each system demonstrate a foundational tension between locally-legitimate actors and nationally-capable political savvy.

The Effects of Private Health Insurance on Universal Health Coverage Objectives in China: A Systematic Literature Review.

BACKGROUND: We conducted a systematic review on the role of private health insurance to complement the social health insurance system towards achieving universal health coverage in China. This review presents the impacts of private health insurance on expanding coverage, increasing access to healthcare, and financial protection. METHODS: A systematic review was conducted by searching peer-reviewed articles published between January 2000 and March 2018 in Web of Science, PubMed, and China Knowledge Resource Integrated Database. The search terms included coverage prevalence, access and financial protection related to private health insurance in China. A total of 31 studies were selected. RESULTS: Coverage prevalence of private health insurance gradually increased but it was unequally distributed across regions and populations. The expansion of social health insurance has enhanced the total aggregate premium of private health insurance but has had a mixed impact on the take-up of private health insurance. Private insurance beneficiaries were found to limit their utilisation of healthcare services and there was no evidence that it ensured financial protection. CONCLUSION: The role of private health insurance (PHI) in extending universal health coverage in China was limited and therefore should not be overstated.

Transforming health care: the policy and politics of service reconfiguration in the UK's four health systems.

Public involvement in service change has been identified as a key facilitator of health care transformation (Foley et al., 2017) but little is known about how health policy influences whether and how organisations involve the public in change processes. This qualitative study compares policy and practice for involving the public in major service changes across the UK's four health systems (England, Northern Ireland, Wales and Scotland). We analysed policy documents, and conducted interviews with officials, stakeholders, NHS staff and public campaigners (total number of interviewees = 47). Involving the public in major service change was acknowledged as a policy challenge in all four systems. Despite ostensible similarities, there were some clear differences between the four health systems' processes for involving patients and the public in major changes to health services. The extent of central Government oversight, the prescriptiveness of Government guidance, the role for intermediary bodies and arrangements for independent scrutiny of contentious decisions all vary. We analyse how health policy in the four systems has used 'sticks' and 'sermons' to promote particular approaches, and conclude that both policy and the wider system context within which health care organisations try to effect change are significant, and understudied aspect of contemporary practice.

Improving the Health of Cambodian Americans: Grassroots Approaches and Root Causes.

BACKGROUND: Cambodian Americans experience great disparities in health compared to other Americans, yet may be underserved by conventional healthcare systems. Community-based participatory research (CBPR) is a means to engage underserved communities in health research and programming. We describe results of our efforts to engage the Cambodian grassroots members as well as formal leaders in Oakland, California. OBJECTIVES: In addition to a community advisory group, we convened a Community Work Group (CWG), composed of 10 grassroots community women of varying ages and backgrounds. The project aimed to leverage the lived experiences of these women and their understandings of health and wellness in identifying specific health issues and developing culturally resonant strategies. METHODS: The CWG met weekly with staff facilitators using methods for collective analysis including theater, body mapping, and other expressive arts. RESULTS: The approach proved logistically challenging, but resulted in novel analyses and strategies. The group identified trauma, along with poor access to education, unemployment and underemployment, social isolation, and generation gap, together with community violence, as root causes of key behavioral health issues, namely, alcohol abuse, gambling, prescription drug misuse, and domestic violence. Strategies proposed and implemented by the group and project staff were a community garden, Cambodian New Year's celebrations, and a museum exhibit on the Cambodian refugee experiences. CONCLUSIONS: Grassroots community engagement can support projects in identifying social determinants of health and developing the capacities of community members to conduct research and actions to improve health.