Health Services Management Research

The problems associated with hospital-acquired infection have been causing increasing concern in England in recent years. This paper reports the results of a nationwide survey of hospital infection control professionals' views concerning the organizational structures used to manage and obtain funding for control of infection. A complex picture with significant variation between hospitals emerges. Although government policy dictates that specific funding for hospital infection control is formally made available, it is not always the case that infection control professionals have adequate resources to undertake their roles. In some cases this reflects the failure of hospitals' infection control budgetary mechanisms; in others it reflects the effects of decentralizing budgets to directorate or ward level. Some use was made of informal mechanisms either to supplement or to substitute for the formal ones. But almost all infection control professionals still believed they were constrained in their ability to protect the hospital population from the risk of infectious disease. It is clear that recent government announcements that increased effort will be made to support local structures and thereby improve the control of hospital acquired infection are to be welcomed.

With increasing competition in the local and regional healthcare markets, and growing interest in assessing the effectiveness of services and patient outcomes, satisfaction measures are becoming prominent in evaluating the performance of the healthcare system. This study examines the independent effect of predisposing, enabling and medical need factors on perceived access to care with particular focus on insurance plans. A survey questionnaire is developed to investigate access limitations at three levels: (1) the health plan, (2) the individual provider(s) and (3) the healthcare organization. In addition, shortage of providers, residents' perceptions of their health status, satisfaction with access to care and socio-demographic indicators are incorporated into the analysis. Multivariate logistic regression is used to assess the independent effects of the above factors on a dichotomous dependent variable - residents' overall satisfaction with access to healthcare services. The most salient determinants of overall satisfaction with access to care were the type of health insurance plan, cost of insurance premiums, co-payments, difficulty with obtaining referrals, self-rated general health, the opportunity cost of taking time to see a provider (measured by the loss of hourly wages), marital status and the age factor over 80 years.

In many countries, local managers and clinicians have been given responsibility to set health priorities and allocate resources accordingly. Although tools have been suggested for use in aiding this process, knowledge of these tools within health regions is lacking and comparative analysis in the literature is limited. Several approaches to priority setting are critiqued from both practical and theoretical perspectives, and a tangible way forward for such activity is provided. The approaches analysed include: needs assessment, core services, economic evaluation including quality-adjusted life year league tables, and programme budgeting and marginal analysis (PBMA). Needs assessment fails to recognize underlying economic principles of opportunity cost and the margin, while core services ignores the margin and has had limited impact in practice. Economic evaluations can consider marginal costs and benefits, but cannot always be used to inform decisions in a timely manner. PBMA is based on underlying economic principles and can pragmatically respond to objectives related to both efficiency and equity. Although PBMA is not without challenges, from an economic perspective, it does seem to 'get the thinking right', and, importantly, as a process, can incorporate some of the other approaches to priority setting discussed in this paper.

The 1999 reform of the Polish healthcare system revealed deficiencies in the research base and a lack of organized systems of information provision. Professionals who most need effective information systems are policymakers and healthcare managers. The main aim of the described study was to obtain data describing the needs, preferences and limitations of healthcare managers as information users, and to identify environmental factors influencing their information behaviour. A national postal survey was conducted and supplemented with information collected during focus groups, semi-structured interviews and through analysis of relevant policy documents. The target population included hospital chief executives, medical directors, head nurses and directors of the institutions responsible for health services planning and purchasing. Target institutions were drawn systematically from official lists, stratified by regions of the country and hospital reference level. The interviews were conducted with primary care unit managers and with Ministry of Health officials. National health strategy and directives, cost-effectiveness analyses of interventions and clinical practice guidelines emerged as information of primary importance to respondents. The main barriers to effective information behaviour were found to be: attitudes towards research activity, lack of appropriately processed data, lack of skills enabling information seeking and appraisal, inappropriate format of publications, ineffective dissemination of information and absence of services facilitating access to evidence. The current information environment of healthcare managers, together with their attitude towards information and deficiencies in information skills, appear to serve as a barrier to evidence-based practice in the Polish healthcare system.

The US healthcare delivery system, by all accounts, is the most advanced and sophisticated healthcare system in the world. Clinical advances in diagnostic and therapeutic regimens, superior performance in biomedical research, and the development and use of the latest management and medical technologies are all hallmarks of the system. While the US healthcare system has been extremely successful, concerns remain about access to care for a large segment of the population. This article examined the various approaches that have been adopted and those that are being proposed to bridge the existing gap in health insurance coverage. The underlying assumptions of the proposed strategies were examined, and the conditions necessary for the successful implementation of these strategies were also discussed.

Executive Letter (95)5 initiated a change of health policy preventing general practitioners (GPs) from prescribing packages of 'high-tech healthcare at home' (HTHC). From 1 April 1995, district health authorities were required to establish contracts to purchase such care. Several reasons were behind this policy change including the belief that contracting would improve service quality by encouraging competition between potential suppliers, securing better value for money, and establishing service specifications and monitoring mechanisms. Our survey of 98 health authorities, however, highlighted that contracting for home total parenteral nutrition, intravenous antibiotics for patients with cystic fibrosis, intravenous chemotherapy and continuous ambulatory peritoneal dialysis is largely undeveloped. The majority of districts contracted with historic providers and authorities freely admitted that they did not know whether they were obtaining value for money or a service of adequate quality. Only three districts had developed a strategy for purchasing HTHC as required by the Executive Letter, and only 17 had plans to re-examine their approach. Contracting for HTHC presents practical problems, including the complexity of the process and the significant time demands for efficient and effective contracting. Phase two of this research sought to produce a 'guide to good practice' for health authorities wishing to re-examine and improve their purchasing. We conducted case study analyses in districts that had made effective progress and those that had encountered difficulties, drawing upon lessons learned. We reported our findings to the NHS Executive and supplemented this with a 'toolbox' that included sample documents covering areas such as tendering, monitoring mechanisms, service specifications and different purchasing approaches.

Objective: This report investigates the use of linear and travelled route (transit network-based) distances in estimating the accessibility of hospitals to patients, for some selected hospital admission diagnostics.

Methods: For patients admitted to 14 public hospitals in Rio de Janeiro City, during 1996, under the ICD-9 headings 'Complications of Pregnancy, Childbirth and the Puerperium' and 'Disorders of the Circulatory System', average distances between the patient's district of residence and hospital of admission were calculated (both as Euclidean and as network-based distances). Data were obtained from the country's public health data processing agency. Geographic co-ordinates were obtained for districts of residence from the postal codes of the patients' residences. Distances were estimated with the TransCAD Geographical Information System, based on a map of the city transit network. There were 8654 patients admitted under the 'Complications of Pregnancy' heading and 3439 under 'Disorders of Circulatory System'.

Results: Variations of up to a factor of 5.3, and up to 34 km, could be identified between linear and network estimates.

Conclusion: While recognizing that network estimates have advantages, the literature on accessibility frequently argues that aerial estimates are a good approximation for those. The present results show that this is not necessarily the case.