Patient decision support interventions for candidates considering elective surgeries: a systematic review and meta-analysis.

BACKGROUND: The increase in elective surgeries and varied postoperative patient outcomes has boosted the use of patient decision support interventions (PDSIs). However, evidence on the effectiveness of PDSIs are not updated. This systematic review aims to summarize the effects of PDSIs for surgical candidates considering elective surgeries and to identify their moderators with an emphasis on the type of targeted surgery. DESIGN: Systematic review and meta-analysis. METHODS: We searched eight electronic databases for randomized controlled trials evaluating PDSIs among elective surgical candidates. We documented the effects on invasive treatment choice, decision-making-related outcomes, patient-reported outcomes, and healthcare resource use. The Cochrane Risk of Bias Tool version 2 and Grading of Recommendations, Assessment, Development, and Evaluations were adopted to rate the risk of bias of individual trials and certainty of evidence, respectively. STATA 16 software was used to conduct the meta-analysis. RESULTS: Fifty-eight trials comprising 14 981 adults from 11 countries were included. Overall, PDSIs had no effect on invasive treatment choice (risk ratio=0.97; 95% CI: 0.90, 1.04), consultation time (mean difference=0.04 min; 95% CI: -0.17, 0.24), or patient-reported outcomes, but had a beneficial effect on decisional conflict (Hedges' g =-0.29; 95% CI: -0.41, -0.16), disease and treatment knowledge (Hedges' g =0.32; 95% CI: 0.15, 0.49), decision-making preparedness (Hedges' g =0.22; 95% CI: 0.09, 0.34), and decision quality (risk ratio=1.98; 95% CI: 1.15, 3.39). Treatment choice varied with surgery type and self-guided PDSIs had a greater effect on disease and treatment knowledge enhancement than clinician-delivered PDSIs. CONCLUSIONS: This review has demonstrated that PDSIs targeting individuals considering elective surgeries had benefited their decision-making by reducing decisional conflict and increasing disease and treatment knowledge, decision-making preparedness, and decision quality. These findings may be used to guide the development and evaluation of new PDSIs for elective surgical care.

Urban/rural differences in preferences for EQ-5D-5L health states: a study of a multi-ethnic region in China.

OBJECTIVES: This study aimed to compare health preferences for EQ-5D-5L health states between urban and rural populations in China. METHODS: This study used pooled secondary data from two EQ-5D-5L valuation studies. Participants were recruited from Guizhou province and Chongqing municipality, China using quota sampling. Each participant was interviewed face-to-face to value a set of 15 or 16 out of 30 EQ-5D-5L health states using time trade-off (TTO) methods including composite TTO and other two variants. Regression analysis was used to compare health state preferences between urban and rural participants. RESULTS: A total of 597 participants (urban: 55.44%; rural: 44.56%) completed the valuation interviews. Both univariate and multivariable linear regression analyses showed that rural participants tended to value health states lower than urban participants regardless of severity of health states. The unadjusted and adjusted overall mean differences between the two groups were - 0.041 (95% confidence interval [CI] - 0.077, - 0.004, p-value = 0.031) and - 0.040 (95% CI - 0.078, - 0.002, p-value = 0.038), respectively. Predictions for the 3125 health states based on rural participants' health preferences were lower than those based on urban participants' health preferences. CONCLUSION: There were small, yet statistically significant, differences in EQ-5D-5L health states preferences between urban and rural populations in China. Future study aiming at establishing a national value set should pay more attention to the sample representativeness.

Censoring in the time trade-off valuation of worse-than-dead EQ-5D-5L health states: can a time-based willingness-to-accept question be the solution?

PURPOSE: The left censoring of values at -1 by design of the composite time trade-off (cTTO) tasks leads to excessive amount of -1 values in some EQ-5D-5L valuation studies. This study aimed to investigate whether a time-based willingness-to-accept (tWTA) question can be used to elicit values lower than -1 and improve the estimation of EQ-5D-5L values. METHODS: At the end of each cTTO task in the Taiwanese EQ-5D-5L valuation study, if the value of the health state was indicated to be lower than -1, a tWTA question eliciting the indifference point between a hypothetical life (i.e. x number of years in full health followed by 10 years in the health state) and immediate death was used to estimate its uncensored value. We compared the statistical characteristics of the censored and uncensored data. RESULTS: Four hundred and twenty-nine of 1,000 respondents were offered the tWTA question in a total of 1,071 cTTO tasks. In 79.55% of those tasks, indifference was not reached. Spearman's correlation with level summary score was -0.41 and -0.40 for negative uncensored and censored data, respectively. The logical inconsistency rates of the uncensored and censored data were 0.88% vs. 0.29%, respectively. Modelling of the uncensored data resulted in coefficients with greater uncertainty and much lower predictions. CONCLUSIONS: The elicitation of values lower than -1 using a tWTA question that grants more time for trading seems not a promising solution to the value censoring of the cTTO tasks. Other strategies for valuation of very poor health states should be explored.

How to evaluate surgical tourism service organizations in China: indicators system development and a pilot application.

BACKGROUND: Surgical tourism is an emerging economic sector, with the most growth potential demonstrated in China's health industry before the COVID-19 pandemic. Surgical tourism accounts for a large part of medical tourism services in China, with high requirements in terms of quality and safety. By contrast, China suffers from insufficient measurement tools and theoretical research. The aim of this study was to develop a set of reliable and feasible indicators by augmenting the Donabedian model to evaluate the quality of surgical tourism services. METHODS: A literature review and focus group interview were used to generate indicators for the quality of surgical tourism services. The basic framework of the evaluation system was based on the structure-process-outcome Donabedian model. The screening and weight setting were conducted through an analytical hierarchy process (AHP) and a two-round Delphi consultation with 13 panelists. The validity and reliability of experts were tested by the experts' positive coefficient, authority coefficient, and coordination coefficient. The reliability of the questionnaire was assessed by a pre-test distributed within an International Medical Department of a public hospital in China. RESULTS: Based on the Donabedian quality theory, a novel evaluation system of surgical tourism service institutions was constructed with three dimensions, nine first-level items and 39 second-level items. The three dimensions consisted of the structure (0.315), process (0.287), and outcome (0.398), with several indicators for each dimension and each indicator was given a weight. Of the two rounds of Delphi consultation, the response rates were 86.67% and 100%. The coordination coefficient of expert opinions in the two rounds of consultation were 0.49 and 0.65 (p < 0.05). For the empirical study, the self-evaluation score of a public hospital was 86, which could rate as a two-star institution. CONCLUSIONS: Our evaluation system identified three suitable quality dimensions of surgical tourism services to improve the safety and quality of practical healthcare. It reflects the access criterion of surgical tourism institutions, provides references for the best choice of surgical services for tourists, and can be applied by healthcare managers and policy makers to allocate resources more efficiently and promote more surgical tourism services with international standards.

Cost-effectiveness analysis of renal replacement therapy strategies in Guangzhou city, southern China.

OBJECTIVES: This study aims to assess the cost-effectiveness of three renal replacement therapy (RRT) modalities as well as proposed changes of scheduled policies in RRT composition in Guangzhou city. METHODS: From a payer perspective, we designed Markov model-based cost-effectiveness analyses to compare the cost-effectiveness of three RRT modalities and four different scheduled policies to RRT modalities in Guangzhou over three time horizons (5, 10 and 15 years). The current situation (scenario 1: haemodialysis (HD), 73%; peritoneal dialysis (PD), 14%; kidney transplantation (TX), 13%) was compared with three different scenarios: an increased proportion of incident RRT patients on PD (scenario 2: HD, 47%; PD, 40%; TX, 13%); on TX (scenario 3: HD, 52%; PD, 14%; TX, 34%); on both PD and TX (Scenario 4: HD, 26%; PD, 40%; TX, 34%). RESULTS: Over 5-year time horizon, HD was dominated by PD. At a willingness-to-pay (WTP) threshold of US$44 300, TX was cost-effective compared with PD with an incremental cost-effectiveness ratio of US$35 518 per quality-adjusted life year (QALY) gained. The scenario 2 held a dominant position over the scenario 1, with a net saving of US$ 5.92 million and an additional gain of 6.24 QALYs. The scenarios 3 and 4 were cost-effective compared with scenario 1 at a WTP threshold of US$44 300. The above results were consistent across the three time horizons. CONCLUSIONS: TX is the most cost-effective RRT modality, followed in order by PD and HD. The strategy with an increased proportion of incident patients on PD and TX is cost-effective compared with the current practice pattern at the given WTP threshold. The planning for RRT service delivery should incorporate efforts to increase the utilisation of PD and TX in China.

Development and validation of an instrument in job evaluation factors of physicians in public hospitals in Beijing, China.

BACKGROUND: Job evaluation has been widely used to establish a foundation for internal equity and other human resource functions. The United Kingdom adopts the National Health Service (NHS) Job Evaluation scheme to determine the pay bands for most NHS staff and ensure equal pay for work of equal value. The challenges of recruiting and retaining physicians in Chinese public hospitals have heightened the need for a reliable job evaluation system to ensure the equality of physician compensation. The aim of this study was to construct job evaluation factors of physicians in Chinese public hospitals based on the NHS Job Evaluation scheme and to examine the reliability and validity of the established system. METHODS: Questionnaire surveys and statistical analyses were used to determine the job evaluation factors for physicians. The preliminary screening of the evaluation factors was based on a literature review, focused interviews with physicians and the Delphi method. Based on the results of preliminary screening, a questionnaire with 25 factors was designed to survey physicians regarding the importance of each factor in physician job evaluation. After the pretest, final questionnaire data were collected from 900 physicians by adopting a stratified sampling from 6 tertiary public hospitals in Beijing. A principal component analysis was used for factor extraction and structural validity analysis. The reliability was determined using Cronbach's alpha. RESULTS: The results of the principal component analysis showed that the 25 physician job evaluation factors were grouped into the 5 dimensions of Task Characteristics, Knowledge, Responsibility, Effort/Environment, and Skills. The Cronbach's alpha coefficients of the five dimensions ranged from 0.841 to 0.909, which indicated a high level of reliability. The result of the factor analysis indicated fair structural validity. The content validity was established by building onto the NHS Job Evaluation scheme and other well-established job evaluation systems. CONCLUSIONS: Our study indicates that the Chinese version of physician job evaluation is an instrument with fair reliability and validity, which fully reflects the characteristics of physicians in Chinese public hospitals. This system can provide an important basis for developing a physician compensation plan and ensuring internal equity in healthcare organizations.

The Cost-Effectiveness of Kidney Replacement Therapy Modalities: A Systematic Review of Full Economic Evaluations.

BACKGROUND: Kidney replacement therapy (KRT) is a lifesaving but costly treatment for patients with end-stage kidney disease (ESKD). The objective of this study was to review full economic evaluations comparing KRT modalities specified as hemodialysis (HD), peritoneal dialysis (PD), and kidney transplantation (KT) for patients with ESKD. METHODS: We conducted a systematic review of the literature from PubMed, Embase, EconLit (EBSCO), Web of Science, Cochrane Library, National Health Service Economic Evaluation Database (NHS EED), Centre for Reviews and Dissemination (CRD) Database of Abstracts of Reviews of Effects (DARE), and CRD Health Technology Assessment Database from inception until 5 January 2020. Full economic evaluations were included if they compared three forms of KRT specified as PD, HD, and KT. The reporting quality of included studies was assessed using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist. RESULTS: Ten studies were identified in the review. The majority of the studies were model-based evaluations and included a cost-utility analysis. Four studies were conducted from a public healthcare perspective, three from a societal perspective, and three from a third-party payer perspective. None of the studies adequately addressed all the applicable items of the CHEERS checklist. The most infrequently reported items were characterizing heterogeneity, target population, and characterizing uncertainty. There is a lack of studies that conduct from a societal perspective and take into account characterizing heterogeneity. All included studies indicate that KT is the most cost-effective KRT modality, with either a dominant position over HD and PD or an incremental cost-effectiveness ratio well below the accepted willingness-to-pay threshold. The majority of studies suggest that PD is less costly and offers comparable or better health outcomes than HD. CONCLUSIONS: Our systematic review suggests that KT is the most cost-effective KRT modality, but there is no firm conclusion about the cost-effectiveness of HD and PD. Further economic evaluations can be conducted from a societal perspective and detail the evidence for subsets of patients with different characteristics.

Implementation and Promotion of Quality Control Circle: A Starter for Quality Improvement in Chinese Hospitals.

PURPOSE: To analyse the quality control circle (QCC) implementation status, tool modification and promotion in hospitals in mainland China. METHODS: Data were collected from the 2013-2018 National Quality Control Circle Competition of Chinese Hospitals. A total of 1913 participating QCCs implemented by 34,023 hospital staff from 915 hospitals across 31 provinces and municipalities were included in this study to analyse the characteristics of QCC implementation status in mainland China, using descriptive analyses. RESULTS: The majority of participating QCCs came from central and eastern hospitals. Most of the QCCs were carried out in tertiary hospitals and focused on themes of safety and patient care. The QCC has been modified in terms of its classification, implementation process, participation mechanism, and ways of dissemination. A series of promotion strategies have been made to promote the implementation of QCCs nationwide, including establishing a professional promotion organization, developing standardized training programmes, and organizing QCC academic events. CONCLUSION: After years of promotion, QCCs are widely used in hospitals and have been modified to fit the practice of healthcare institutions. The QCC promotion strategies in China can offer valuable insights for other countries that are also making efforts to continuously improve care quality in healthcare institutions.

Quality control circle: a tool for enhancing perceptions of patient safety culture among hospital staff in Chinese hospitals.

OBJECTIVE: To explore whether quality control circle (QCC) is associated with hospital staff's perceptions of patient safety culture (PSC). DESIGN: A cross-sectional survey in 12 public hospitals from October to December 2018 and a longitudinal survey in one public hospital from November 2017 to November 2018. SETTING: In 12 public hospitals from six provinces located in eastern, central and western of China, and one public hospital in eastern China. PARTICIPANTS: In total, 811 and 102 hospital staff participated in the cross-sectional survey and the longitudinal survey, respectively. These participants included doctors, nurses, medical technicians and administrative staff. MAIN OUTCOME MEASURES: Hospital staff's perceptions of PSC were measured by the Hospital Survey on Patient Safety Culture (HSOPSC) questionnaire. The association between QCC implementation and PSC was identified by univariate analysis and multiple linear regression analysis. RESULTS: Univariate analysis showed that the staff from hospitals that had implemented QCC received significantly higher HSOPSC scores than those from hospitals where QCC had not been implemented (3.73 ± 0.61 vs. 3.57 ± 0.41, P < 0.05). The QCC implementation was a significant predictor in the established multiple linear regression model. One year after QCC implementation, the hospital involved in the longitudinal survey scored higher in HSOPSC than before (3.75 ± 0.42 vs. 3.60 ± 0.36, P < 0.001). CONCLUSIONS: QCC implementation was positively associated with PSC and the former could promote the establishment of the latter. It is suggested that QCC can play an active role in enhancing PSC so as to further improve patient safety management.