Effects of practice setting on GPs' provision of care.

OBJECTIVE: To define a physician classification system based on practice settings and to analyze the service provision associated with those classifications. DESIGN: A cross-sectional, retrospective study. SETTING: Province of Quebec. PARTICIPANTS: All GPs in Quebec in 2002 who had been practising for at least 2 years. MAIN OUTCOME MEASURES: Practice setting variables were based on physician income in the different settings. Service provision was assessed using indicators related to continuity, comprehensiveness, accessibility, and productivity of services provided by the GPs. A multiple correspondence analysis with ascending hierarchical classification was conducted to construct the taxonomy of GPs based on their practice settings. RESULTS: Our study produced 7 practice setting models. Two were essentially single-practice models. The 5 others combined several settings. Service provision varied from one model to another. Continuity was greater in the private practice model, in which older GPs were predominant, while accessibility was greater in multi-institutional practice models, in which younger GPs were more active. CONCLUSION: To ensure balance between continuity, accessibility, and comprehensiveness in primary care services provided by GPs, it is important to consider the service provision associated with different practice models.

Health care system performance of 27 OECD countries.

The article is based on a multidimensional conception of healthcare system performance. Our objectives are to assess the performance of the healthcare systems of 27 Organisation for Economic Co-operation and Development (OECD) countries and to discern the countries' profiles according to the homogeneity of their healthcare systems' levels of performance. The analyses were carried out on data collected from the 27 high-income OECD countries, primarily using the OECD Health Data 2007 database, the World Health Organization 2008 statistics, OECD Health at a Glance and OECD Social Indicators. Each healthcare system's performance was assessed on the basis of the volume of available resources, services produced and health outcomes achieved and efficiency, effectiveness and productivity, thus characterizing the investments made in proportion to the available resources and services produced. Overall performance profiles were constructed taking into account simultaneously the level of all these components. Using multiple clusters analysis, we were able to group the countries into four profiles (satisfactory, promising, weak-polarized and limited) according to the homogeneity of their performance levels. This article offers a broad overview of the performance of these healthcare systems. The results will enable decision-makers to know the strengths and weaknesses of their own health care system and also to compare it with those of other countries.

A global approach to evaluation of health services utilization: concepts and measures.

Health services utilization has been the object of many books and papers in the literature. Measures associated with utilization are often a function of volume of services. The objective of this paper is to present a comprehensive approach to the evaluation of health services utilization and of associated measures, using databases. Based on the theoretical framework of Starfield (1998), we analyze health services utilization with the help of indicators that are not directly linked to volume but that indirectly provide an estimate, while also documenting the qualitative aspects of utilization. The indicators mark accessibility, continuity, comprehensiveness and productivity of care. Once the concepts have been defined, we propose their operationalization using the databases. We then present the advantages of multidimensional conceptualization of health services utilization through a simultaneous analysis of these indicators. Researchers and decision-makers in public health and health planning have much to gain from this innovative multidimensional approach, which presents a dynamic conceptualization of health services utilization based on health administrative data.This paper was originally published in French, in the journal Pratiques et Organisation des Soins 2011 42(1): 11-18.

ÉVALUER UNE INTERVENTION COMPLEXE: ENJEUX CONCEPTUELS, MÉTHODOLOGIQUES, ET OPÉRATIONNELS.

Theoretically, evaluation should help decision-makers address contemporary health system challenges. Paradoxically, the use of evaluation results by decision-makers remains poor, despite rapid development in the evaluation field. The level of use depends on the evaluator's ability to account for the complexity of health-care systems. The complex nature of an intervention often compels evaluators to adopt unconventional approaches to account for the roles of the players. The evaluation of a complex intervention raises conceptual, methodological, and operational challenges the evaluation has to overcome to increase the level of use of its findings by decision-makers.

Avaliação: conceitos e métodos / Rating: concepts and methods

Membros do Grupo de Pesquisa Interdisciplinar em Saúde da Universidade de Montreal, no Canadá, criaram um modelo para a avaliação das intervenções em saúde e o apresentaram – pela primeira vez de forma completa – em 2009, em um livro em francês. A publicação, dirigida especialmente a pesquisadores e gestores, foi traduzida para o português e lançada no Brasil pela Editora Fiocruz. O modelo de que trata o livro, desenvolvido há duas décadas, foi testado com sucesso em pesquisas avaliativas realizadas não só no Canadá, mas também em países da Europa, África e América do Sul, especialmente no Brasil. As indicações contidas no livro podem ser aplicadas para a avaliação de diferentes intervenções em saúde, como políticas, programas, organizações, tratamentos e tecnologias. Mas “o modelo de avaliação proposto é suficientemente amplo e global para ser utilizado em outros campos tais como a educação, os serviços sociais ou a administração pública, para citar somente esses”, sublinham os organizadores. Os capítulos detalham seis tipos de avaliação: análise estratégica; análise lógica; análise da produção; análise dos efeitos; análise econômica; e análise da implantação.

Avaliação: Conceitos e métodos

Membros do Grupo de Pesquisa Interdisciplinar em Saúde da Universidade de Montreal, no Canadá, criaram um modelo para a avaliação das intervenções em saúde e o apresentaram – pela primeira vez de forma completa – em 2009, em um livro em francês. A publicação, dirigida especialmente a pesquisadores e gestores, foi traduzida para o português e lançada no Brasil pela Editora Fiocruz. O modelo de que trata o livro, desenvolvido há duas décadas, foi testado com sucesso em pesquisas avaliativas realizadas não só no Canadá, mas também em países da Europa, África e América do Sul, especialmente no Brasil. As indicações contidas no livro podem ser aplicadas para a avaliação de diferentes intervenções em saúde, como políticas, programas, organizações, tratamentos e tecnologias. Mas “o modelo de avaliação proposto é suficientemente amplo e global para ser utilizado em outros campos tais como a educação, os serviços sociais ou a administração pública, para citar somente esses”, sublinham os organizadores. Os capítulos detalham seis tipos de avaliação: análise estratégica; análise lógica; análise da produção; análise dos efeitos; análise econômica; e análise da implantação

The role (or not) of economic evaluation at the micro level: can Bourdieu's theory provide a way forward for clinical decision-making?

Despite increasing interest in health economic evaluation, investigations have shown limited use by micro (clinical) level decision-makers. A considerable amount of health decisions take place daily at the point of the clinical encounter; especially in primary care. Since every decision has an opportunity cost, ignoring economic information in family physicians' (FPs) decision-making may have a broad impact on health care efficiency. Knowledge translation of economic evaluation is often based on taken-for-granted assumptions about actors' interests and interactions, neglecting much of the complexity of social reality. Health economics literature frequently assumes a rational and linear decision-making process. Clinical decision-making is in fact a complex social, dynamic, multifaceted process, involving relationships and contextual embeddedness. FPs are embedded in complex social networks that have a significant impact on skills, attitudes, knowledge, practices, and on the information being used. Because of their socially constructed nature, understanding preferences, professional culture, practices, and knowledge translation requires serious attention to social reality. There has been little exploration by health economists of whether the problem may be more fundamental and reside in a misunderstanding of the process of decision-making. There is a need to enhance our understanding of the role of economic evaluation in decision-making from a disciplinary perspective different than health economics. This paper argues for a different conceptualization of the role of economic evaluation in FPs' decision-making, and proposes Bourdieu's sociological theory as a research framework. Bourdieu's theory of practice illustrates how the context-sensitive nature of practice must be understood as a socially constituted practical knowledge. The proposed approach could substantially contribute to a more complex understanding of the role of economic evaluation in FPs' decision-making.

Does accreditation stimulate change? A study of the impact of the accreditation process on Canadian healthcare organizations.

BACKGROUND: One way to improve quality and safety in healthcare organizations (HCOs) is through accreditation. Accreditation is a rigorous external evaluation process that comprises self-assessment against a given set of standards, an on-site survey followed by a report with or without recommendations, and the award or refusal of accreditation status. This study evaluates how the accreditation process helps introduce organizational changes that enhance the quality and safety of care. METHODS: We used an embedded multiple case study design to explore organizational characteristics and identify changes linked to the accreditation process. We employed a theoretical framework to analyze various elements and for each case, we interviewed top managers, conducted focus groups with staff directly involved in the accreditation process, and analyzed self-assessment reports, accreditation reports and other case-related documents. RESULTS: The context in which accreditation took place, including the organizational context, influenced the type of change dynamics that occurred in HCOs. Furthermore, while accreditation itself was not necessarily the element that initiated change, the accreditation process was a highly effective tool for (i) accelerating integration and stimulating a spirit of cooperation in newly merged HCOs; (ii) helping to introduce continuous quality improvement programs to newly accredited or not-yet-accredited organizations; (iii) creating new leadership for quality improvement initiatives; (iv) increasing social capital by giving staff the opportunity to develop relationships; and (v) fostering links between HCOs and other stakeholders. The study also found that HCOs' motivation to introduce accreditation-related changes dwindled over time. CONCLUSIONS: We conclude that the accreditation process is an effective leitmotiv for the introduction of change but is nonetheless subject to a learning cycle and a learning curve. Institutions invest greatly to conform to the first accreditation visit and reap the greatest benefits in the next three accreditation cycles (3 to 10 years after initial accreditation). After 10 years, however, institutions begin to find accreditation less challenging. To maximize the benefits of the accreditation process, HCOs and accrediting bodies must seek ways to take full advantage of each stage of the accreditation process over time.

Saúde e cidadania: as experiências do Brasil e do Quebec / Health and citizenship: experiences from Brazil and Quebec

Esta obra foi realizada tendo por base textos preparados para o primeiro simpósio internacional da Conferência Luso-Francófona da Saúde (COLUFRAS). A presente obra foi concebida como um diálogo entre as problemáticas que ocorrem no Quebec e aquelas que preocupam o Brasil. Ela apresenta um vasto panorama das questões de saúde dos dois países e às quais todos os países devem responder para que, no século XXI, cada cidadão possa ter acesso aos tratamentos quando deles precisar, e para que a saúde pública seja levada em conta nas políticas públicas. Diversos temas são tratados neste volume, escritos por brasileiros e canadenses, particularmente por especialistas do sistema de saúde do Quebec. Assuntos da maior relevância foram tratados nesta obra, como a experiência cidadã e o sistema de saúde quebequense, o financiamento dos cuidados de saúde naquela província, organizações para reformar o sistema de saúde, elementos de arquitetura dos sistemas de avaliação do desempenho dos serviços de saúde, o capital humano na área da saúde no Quebec e a institucionalização da cooperação internacional centrada no cidadão. Importante destacar ainda que o Brasil vem firmando acordos com o Canadá, especialmente com o Quebec, na área da saúde, podendo ser destacadas as participações do Conselho Nacional de Secretários de Saúde – CONASS e do Conselho Nacional de Secretarias Municipais de Saúde – CONASEMS, em razão de ambos os países comungarem dos mesmos valores de justiça social e equidade. A leitura deste livro certamente trará reflexões importantes na área da saúde, podendo contribuir para a ampliação dos conhecimentos e sua aplicação no sistema de saúde brasileiro.

Understanding the social patterning of smoking practices: a dynamic typology.

In many countries, cigarette consumption has been on a declining trend for over 20 years. However, different patterns of smoking practices have emerged. Our goal is to explore how the patterning of smoking practices occurs and persists over time, and to investigate the factors that could help interpret these patterns. Data were derived from the National Population Health Surveys and comprise a large representative sample of the population. Dynamic Typology methods reveal two main classes of typology: monothetic groups with stable patterns of behaviour over time (never-smokers, chronically addicted smokers, long-term ex-smokers); and polythetic groups with substantial behavioural variations. Moreover, socioeconomic inequalities are found among all groups, and gender-specific clusters of behaviour become apparent, with specific risk groups, such as the group of young women aged 20-24 at risk of becoming highly addicted. Our results also show that the effects of socioeconomic position on smoking practices are not significantly mediated by psychosocial variables such as self-esteem and personal control in both females and males. However, these variables still exert independent and differential effects on smoking practices in both genders. Our findings indicate that analysis of temporal patterns of smoking is crucial for tailoring type and timing of health-promoting interventions.

The role of economic evaluation in the decision-making process of family physicians: design and methods of a qualitative embedded multiple-case study.

BACKGROUND: A considerable amount of resource allocation decisions take place daily at the point of the clinical encounter; especially in primary care, where 80 percent of health problems are managed. Ignoring economic evaluation evidence in individual clinical decision-making may have a broad impact on the efficiency of health services. To date, almost all studies on the use of economic evaluation in decision-making used a quantitative approach, and few investigated decision-making at the clinical level. An important question is whether economic evaluations affect clinical practice. The project is an intervention research study designed to understand the role of economic evaluation in the decision-making process of family physicians (FPs). The contributions of the project will be from the perspective of Pierre Bourdieu's sociological theory. METHODS/DESIGN: A qualitative research strategy is proposed. We will conduct an embedded multiple-case study design. Ten case studies will be performed. The FPs will be the unit of analysis. The sampling strategies will be directed towards theoretical generalization. The 10 selected cases will be intended to reflect a diversity of FPs. There will be two embedded units of analysis: FPs (micro-level of analysis) and field of family medicine (macro-level of analysis). The division of the determinants of practice/behaviour into two groups, corresponding to the macro-structural level and the micro-individual level, is the basis for Bourdieu's mode of analysis. The sources of data collection for the micro-level analysis will be 10 life history interviews with FPs, documents and observational evidence. The sources of data collection for the macro-level analysis will be documents and 9 open-ended, focused interviews with key informants from medical associations and academic institutions. The analytic induction approach to data analysis will be used. A list of codes will be generated based on both the original framework and new themes introduced by the participants. We will conduct within-case and cross-case analyses of the data. DISCUSSION: The question of the role of economic evaluation in FPs' decision-making is of great interest to scientists, health care practitioners, managers and policy-makers, as well as to consultants, industry, and society. It is believed that the proposed research approach will make an original contribution to the development of knowledge, both empirical and theoretical.

Evaluating Service Organization Models: The Relevance and Methodological Challenges of a Configurational Approach.

Based on the example of the evaluation of service organization models, this article shows how a configurational approach overcomes the limits of traditional methods which for the most part have studied the individual components of various models considered independently of one another. These traditional methods have led to results (observed effects) that are difficult to interpret. The configurational approach, in contrast, is based on the hypothesis that effects are associated with a set of internally coherent model features that form various configurations. These configurations, like their effects, are context-dependent. We explore the theoretical basis of the configuration approach in order to emphasize its relevance, and discuss the methodological challenges inherent in the application of this approach through an in-depth analysis of the scientific literature. We also propose methodological solutions to these challenges. We illustrate from an example how a configurational approach has been used to evaluate primary care models. Finally, we begin a discussion on the implications of this new evaluation approach for the scientific and decision-making communities.

Hospital performance: competing or shared values?

OBJECTIVE: To find out which are the emerging views on hospital performance and to analyze how these views vary among hospital stakeholders. STUDY SETTING: Three hospital stakeholder groups (physicians, caregivers, and administrative staff) in a large Paris teaching hospital. STUDY DESIGN: A case study combining a qualitative (interviews of 80 key hospital stakeholders and a survey of hospital staff), and a quantitative analysis (a questionnaire composed of 4 theoretical dimensions, 13 sub-dimensions, 66 items) with triangulation of the results. RESULTS: Hospital stakeholders assign greatest importance to the human relations dimension, i.e., organizational climate (professional and public service values) and quality of work life. These values attract a high degree of consensus among stakeholders (no statistical difference between physicians, caregivers and administrative staff). CONCLUSIONS: Our findings challenge the mainstream view that competing values underlie hospital performance. Currently, views are to some extent shared among different stakeholder groups. A reason for this could be the need to form a more united front in the face of recent reforms. This common emphasis on professional and public service values could be the basis for formulating management priorities in teaching hospitals in order to improve performance.

[An accreditation process for public health. Is is possible? Is it desirable?]. / Un processus d'agrément pour la santé publique: est-ce possible? Est-ce souhaitable?

OBJECTIVES: The objective of this pan-Canadian study was to evaluate the feasibility of developing a set of accreditation standards supported by an accreditation process for public health in Canada. METHODS: Twenty-four telephone interviews were conducted, recorded, transcribed and analyzed. RESULTS: The scope of public health implied in respondents' answers included health protection, health promotion, disease prevention and surveillance. A large majority of the experts were in favour of implementing accreditation in public health. Of these, close to two thirds answered that public health needed its own standards to address some of the current gaps. People in health systems were faster to question the relevance of separate standards for public health to avoid creating artificial barriers within the continuum of care. Respondents who opposed an accreditation process for public health cited the lack of capacity currently in the system. Yet, proponents argued that accreditation could actually be used as a capacity-building tool and assist "to fight the tyranny of the urgent". Some identified the actual process of developing accreditation standards for public health as being a valuable exercise. CONCLUSION: It appears that public health in Canada would benefit from an accreditation process developed in consultation with the field, to enhance visibility, capacity building, and performance through pan-Canadian standards which would also have to be flexible enough to accommodate specific provincial and local contexts.

Avaliando a institucionalização da avaliação / Evaluating the institutionalization of evaluation

O artigo aborda os desafios em torno da necessidade de conceber e implantar uma cultura de avaliação. São discutidas as relações e diferenças entre pesquisa avaliativa, avaliação normativa e tomada de decisão. A análise mostra que a capacidade de institucionalização da avaliação como instrumento para melhorar o sistema de saúde é paradoxal, pois supõe que a informação produzida contribua para uma racionalização dos processos de decisão. Postula-se que o grau em que os resultados de uma avaliação são levados em conta pelas instâncias decisórias varia de acordo com a credibilidade, fundamentação teórica e pertinência das avaliações. Observa-se que atores que ocupam diferentes posições não conseguem chegar a um consenso quanto à pertinência dos resultados produzidos pela avaliação. Para fazer com que a avaliação esteja no cerne das estratégias de transformação do sistema de saúde, sugere-se criar condições para um julgamento avaliativo verdadeiramente crítico, com a implementação de estratégias que favoreçam a formação e o aprendizado, o debate, a reflexão e a abertura de novas frentes de intervenção. Institucionalizar a avaliação implica antes de tudo se questionar a capacidade da avaliação de produzir as informações e julgamentos necessários para ajudar as instâncias decisórias a melhorar o desempenho do SUS.

This article approaches the challenges posed by the need to conceive and implement a culture of evaluation. For this purpose it discusses the relations and differences between evaluative research, normative evaluation and decision-making. The analysis shows the capacity to institutionalize the evaluation as a tool for improving the health system to be self-contradictory, for presupposing that the information produced by an evaluation helps to rationalize the decision processes. It is affirmed that the degree to which the results of an evaluation are taken into consideration by decision-makers varies according to their credibility, theoretical foundation and pertinence. What can be observed is that the actors occupying different positions are unable to agree upon the pertinence of the results produced by the evaluation. For turning evaluation into a core-strategy for transforming the health system the author suggests to create the conditions for a truly critical judgment through implementation of strategies that favor professional qualification and instruction, debates, reflections and the opening of new horizons of intervention. Institutionalize the evaluation implies in the first place in questioning the capacity of this evaluation to produce the information and judgments the decision-makers need for improving the performance of the SUS.

Integrated services for frail elders (SIPA): a trial of a model for Canada.

The complex formed by chronic illness, episodes of acute illness, physiological disabilities, functional limitations, and cognitive problems is prevalent among frail elderly persons. These individuals rely on assistance from social and health care programs, which in Canada are still fragmented. SIPA (Services intégrés pour les personnes âgées fragiles) is an integrated service model based on community services, a multidisciplinary team, case management that retains clinical responsibility for all the health and social services required, and the capacity to mobilize resources as required and according to the care protocol. The SIPA demonstration project used an experimental design, with random allocation of the 1,230 participants from two areas of Montreal to an experimental and a control group. The costs of institutional services were $4,270 less for those in the SIPA group compared to the control group; the costs of community care were $3,394 more. The proportion of persons waiting in acute care hospitals for nursing home placement was twice as high in the control group as in the SIPA group. The costs of acute hospitalizations for persons in the SIPA group with ADL disabilities were at least $4,000 lower than those for persons in the control group. In conclusion, the SIPA trial showed that it is possible to undertake ambitious and rigorous demonstration projects in Canada. These results were obtained without an increase in the overall costs of health and social services, without reducing the quality of care, and without increasing the burden on elderly persons and their relatives.

A system of integrated care for older persons with disabilities in Canada: results from a randomized controlled trial.

BACKGROUND: Care for elderly persons with disabilities is usually characterized by fragmentation, often leading to more intrusive and expensive forms of care such as hospitalization and institutionalization. There has been increasing interest in the ability of integrated models to improve health, satisfaction, and service utilization outcomes. METHODS: A program of integrated care for vulnerable community-dwelling elderly persons (SIPA [French acronym for System of Integrated Care for Older Persons]) was compared to usual care with a randomized control trial. SIPA offered community-based care with local agencies responsible for the full range and coordination of community and institutional (acute and long-term) health and social services. Primary outcomes were utilization and public costs of institutional and community care. Secondary outcomes included health status, satisfaction with care, caregiver burden, and out-of-pocket expenses. RESULTS: Accessibility was increased for health and social home care with increased intensification of home health care. There was a 50% reduction in hospital alternate level inpatient stays ("bed blockers") but no significant differences in utilization and costs of emergency department, hospital acute inpatient, and nursing home stays. For all study participants, average community costs per person were C dollar 3390 higher in the SIPA group but institutional costs were C dollar 3770 lower with, as hypothesized, no difference in total overall costs per person in the two groups. Satisfaction was increased for SIPA caregivers with no increase in caregiver burden or out-of-pocket costs. As expected, there was no difference in health outcomes. CONCLUSIONS: Integrated systems appear to be feasible and have the potential to reduce hospital and nursing home utilization without increasing costs.

Vers une réconciliation des théories et de la pratique de l'évaluation, perspectives d'avenir.

Evaluation practitioners encounter various questions while conducting evaluation projects. First, how can the evaluator define the intervention which is to be evaluated? Second, how should the evaluator consider the change? Third, how can use of the evaluation be encouraged? All three preoccupations have found answers in the theoretical developments of program evaluation, whether through implementation evaluation, intervention analysis or participative approaches. However, prolific theoretical developments, while enriching the strategies available to us, may also lead paradoxically to confusion and to difficulties in the transposition of new knowledge into practice. First, we will illustrate the three main difficulties the evaluator is confronted with during practice. Then we will review the different answers offered by evaluation theory. Finally, we will analyze the potential contributions and difficulties which these developments bring to evaluation practice. In conclusion, we will discuss future avenues for facilitating the appropriation of evaluation theories into practice.