Subgroups of High-cost Patients and Their Preventable Inpatient Cost in Rural China.

BACKGROUND: High-cost patients account for most healthcare costs and are highly heterogeneous. This study aims to classify high-cost patients into clinically homogeneous subgroups, describe healthcare utilization patterns of subgroups, and identify subgroups with relatively high preventable inpatient cost (PIC) in rural China. METHODS: A population-based retrospective study was performed using claims data in Xi County, Henan Province. 32,108 high-cost patients, representing the top 10% of individuals with the highest total spending, were identified. A density-based clustering algorithm combined with expert opinions were used to group high-cost patients. Healthcare utilization (including admissions, length of stay and outpatient visits) and spending characteristics (including total spending, and the proportion of PIC, inpatient and out-of-pocket spending on total spending) were described among subgroups. PIC was calculated based on potentially preventable hospitalizations which were identified according to the Agency for Healthcare Research and Quality Prevention Quality Indicators algorithm. RESULTS: High-cost patients were more likely to be older (M=51.87, SD=22.28), male (49.03%) and from poverty-stricken families (37.67%) than non-high-cost patients, with 2.49 (SD=2.47) admissions and 3.25 (SD=4.52) outpatient visits annually. Fourteen subgroups of high-cost patients were identified: chronic disease, non-trauma diseases which need surgery, female disease, cancer, eye disease, respiratory infection/inflammation, skin disease, fracture, liver disease, vertigo syndrome and cerebral infarction, mental disease, arthritis, renal failure, other neurological disorders. The annual admissions ranged from 1.83 (SD=1.23, fracture) to 12.21 (SD=9.26, renal failure), and the average length of stay ranged from 6.61 (SD=10.00, eye disease) to 32.11 (SD=28.78, mental disease) days among subgroups. The chronic disease subgroup showed the largest proportion of PIC on total spending (10.57%). CONCLUSION: High-cost patients were classified into 14 clinically distinct subgroups which had different healthcare utilization and spending characteristics. Different targeted strategies may be needed for subgroups to reduce preventable hospitalizations. Priority should be given to high-cost patients with chronic diseases.

Social care data and its fitness for integrated health and social care service governance: an exploratory qualitative analysis in the Dutch context.

INTRODUCTION: To date, little is known on how social care data could be used to inform performance-based governance to accelerate progress towards integrated health and social care. OBJECTIVES AND DESIGN: This study aims to perform a descriptive evaluation of available social care data in the Netherlands and its fitness for integrated health and social care service governance. An exploratory mixed-method qualitative study was undertaken based on desktop research (41 included indicators), semi-structured expert interviews (13 interviews including 18 experts) and a reflection session (10 experts). SETTING: The Netherlands; social care is care provided in accordance with the Social Support Act, the Participation Law and the Law for Municipal debt-counselling. RESULTS: This study found six current uses for social care data: (a) communication and accountability, (b) monitoring social care policy, (c) early warning systems, (d) controls and fraud detection, (e) outreaching efforts and (f) prioritisation. Further optimisation should be sought through: standardisation, management of data exchange across domains, awareness of the link between registration and financing, strengthening the overall trust in data sharing. The study found five ways the enhanced social care data could be used to improve the governance of integrated health and social care services: (a) cross-domain learning and cooperation (eg, through benchmarks), (b) preventative measures and early warning systems, (c) give insight regarding the quality and effectivity of social care in a broader perspective, (d) clearer accountability of social care towards contracting parties and policy, (e) enable cross-sector data-driven governance model. CONCLUSION: Although there are several innovative initiatives for the optimisation of the use of social care data in the Netherlands, the current social care data landscape and management is not yet fit to support the new policy initiatives to strengthen integrated health and social care service governance. Directions for addressing the shortcomings are provided.

Factors that Promote and Protect Against Financial Toxicity after Orthopaedic Trauma: A Qualitative Study.

INTRODUCTION: Financial toxicity is highly prevalent in patients after an orthopaedic injury. However, little is known regarding the conditions that promote and protect against this financial distress. Our objective was to understand the factors that cause and protect against financial toxicity after a lower extremity fracture. METHODS: A qualitative study was conducted using semi-structured interviews with 20 patients 3 months after surgical treatment of a lower extremity fracture. The interviews were audio-recorded, transcribed verbatim, and analyzed using thematic analysis to identify themes and subthemes. Data saturation occurred after 15 interviews. The percentage of patients who described the identified themes are reported. RESULTS: A total of 20 patients (median age, 44 years [IQR, 38 to 58]; 60% male) participated in the study. The most common injury was a distal tibia fracture (n = 8; 40%). Eleven themes that promoted financial distress were identified, the most common being work effects (n = 14; 70%) and emotional health (n = 12; 60%). Over half (n = 11; 55%) of participants described financial toxicity arising from an inability to access social welfare programs. Seven themes that protected against financial distress were also identified, including insurance (n = 17; 85%) and support from friends and family (n = 17; 85%). Over half (n = 13; 65%) of the participants discussed the support they received from their healthcare team, which encompassed expectation setting and connections to financial aid and other services. Employment protection and workplace flexibility were additional protective themes. CONCLUSION: This qualitative study of orthopaedic trauma patients found work and emotional health-related factors to be primary drivers of financial toxicity after injury. Insurance and support from friends and family were the most frequently reported protective factors. Many participants described the pivotal role of the healthcare team in establishing recovery expectations and facilitating access to social welfare programs.

Relation between pre-existing quality management measures and prevention and containment of COVID-19 outbreaks in 159 nursing homes in Tuscany: a mixed methods study.

BACKGROUND: Nursing homes were often the focus of COVID-19 outbreaks. Many factors are known to influence the ability of a nursing home to prevent and contain a COVID-19 outbreak. The role of an organisation's quality management prior to the pandemic is not yet clear. In the Italian region of Tuscany nursing home performance indicators have been regularly collected since before the pandemic, providing the opportunity to better understand this relationship. OBJECTIVES: To test if there is a difference in the results achieved by nursing homes in Tuscany on 13 quality management indicators, when grouped by severity of COVID-19 outbreaks; and to better understand how these indicators may be related to the ability to control COVID-19 outbreaks, from the perspective of nursing homes. METHODS: We used a mixed methods sequential explanatory design. Based on regional and national databases, 159 nursing homes in Tuscany were divided into four groups by outbreak severity. We tested the significance of the differences between the groups with respect to 13 quality management indicators. The potential relation of these indicators to COVID-19 outbreaks was discussed with 29 managers and other nursing homes' staff through four group interviews. RESULTS: The quantitative analysis showed significant differences between the groups of nursing homes for 3 of the 13 indicators. From the perspective of nursing homes, the indicators might not be good at capturing important aspects of the ability to control COVID-19 outbreaks. For example, while staffing availability is seen as essential, the staff-to-bed ratio does not capture the turn-over of staff and temporary absences due to positive COVID-19 testing of staff. CONCLUSIONS: Though currently collected indicators are key for overall performance monitoring and improvement, further refinement of the set of quality management indicators is needed to clarify the relationship with nursing homes' ability to control COVID-19 outbreaks.

COVID-19 Disruption To Routine Health Care Services: How 8 Latin American And Caribbean Countries Responded.

Latin America and the Caribbean was one of the regions hardest hit globally by SARS-CoV-2. This qualitative exploratory study examined how the COVID-19 pandemic disrupted the delivery of routine health services from the perspective of health care system decision makers and managers. Between May and December 2022, we conducted forty-two semistructured interviews with decision makers from ministries of health and health care managers with responsibilities during the COVID-19 pandemic in eight countries in Latin America and the Caribbean. On the basis of these interviews, we identified themes in three domains: impacts on the provision of routine health services, including postponed and forgone primary care and hospital services; barriers to maintaining routine health services due to preexisting structural health care system weaknesses and difficulties attributed to the pandemic; and innovative strategies to sustain and recover services such as public-private financing and coordination, telemedicine, and new roles for primary care. In the short term, policy efforts should focus on recovering postponed services, including those for noncommunicable diseases. Medium- and long-term health care system reforms should strengthen primary care and address structural issues, such as fragmentation, to promote more resilient health care systems.

Exploring Inequalities in the Use, Quality, and Outcome of the Diabetes Management Program of Indonesian National Health Insurance.

Introduction: Access to diabetes management programs is crucial to control the increasing contribution of diabetes to the global burden of disease. However, evidence regarding whether such services are equally accessible for all population groups is still lacking, particularly in the context of low-middle-income countries and under the National Health Insurance (NHI). This study aimed to assess the extent of socioeconomic and geographical inequalities in the use, quality, and outcome of a diabetes management program for beneficiaries of Indonesian NHI. Methods: A total of 628 participants in the NHI diabetes management program in Banyumas District, Indonesia, were included in 2021 in this cross-sectional study. The main variables measured were regular visits to primary care facilities, standard medication, and glycemic control. The rate difference and rate ratio of age-sex standardized prevalence rates, as well as multiple logistic regressions, were used to measure the extent of inequalities. Results: Around 70% of participants regularly visited primary care facilities and received standard medication, but only 35% had good glycemic control. Highly educated participants were more likely to have regular visits compared to low-educated participants (odds ratio [OR] 1.92; 95% confidence interval [95% CI]: 1.04-3.56). Based on employment and type of NHI beneficiaries, a small extent and even reverse inequalities were found although these findings were insignificant statistically. Urban residents were also more likely to have regular visits (OR 6.61; 95% CI: 2.90-15.08), receive standard medication (OR 9.73; 95% CI: 3.66-25.90), and have good glycemic control (OR 3.85; 95% CI: 1.68-8.83) compared to rural residents. Conclusions: Evidence on the extent of socioeconomic inequalities is inconclusive but substantial geographical inequalities in the use, quality, and outcome of diabetes management programs exist among Indonesian NHI beneficiaries. Future implementation policies of the program should consider particularly the geographical characteristics of participants to avoid and reduce inequalities and, hence, the disease burden of diabetes.

Characterizing Potentially Preventable Hospitalizations of High-Cost Patients in Rural China.

INTRODUCTION: High-cost patients are characterized by repeated hospitalizations, and inpatient cost accounts for a large proportion of their total health care spending. This study aimed to assess the occurrence and costs of potentially preventable hospitalizations and explore contributing factors among high-cost patients in rural China. METHODS: We examined a population-based sample of patients using the 2016 New Rural Cooperative Medical Scheme in Dangyang city, China. Eighteen thousand forty-three high-cost patients were identified. A validated tool and logistic regression analysis were used to determine preventable hospitalizations and their patient-level and supply-side factors. RESULTS: High-cost patients were older (average age of 54 years) than non-high-cost patients (50 years) and more likely to come from poverty-stricken families. The occurrence of preventable hospitalization was 21.65% among high-cost patients. The proportion of preventable inpatient cost in total inpatient and outpatient expenditure among high-cost patients (5.81%) was lower than that of non-high-cost patients (7.88%) but accounted for 75.87% of the overall preventable inpatient cost. High-cost patients with more hospitalizations were more likely to experience preventable hospitalization, and those with heart failure, COPD, diabetes and mixed conditions were at a higher risk of preventable hospitalization, while those with more outpatient visits were less likely to show preventable hospitalization. CONCLUSIONS: The occurrence of preventable hospitalization among high-cost patients in rural China was sizeable. The preventable inpatient cost of the overall population was concentrated among high-cost patients. Interventions such as improving preventive care and disease management targeting high-cost patients within counties may improve patients' health outcomes and quality of life and reduce overall preventable inpatient cost.

Engaging citizens in the development of a health system performance assessment framework: a case study in Ireland.

BACKGROUND: The launch in 2017 of the Irish 10-year reform programme Sláintecare represents a key commitment in the future of the health system. An important component of the programme was the development of a health system performance assessment (HSPA) framework. In 2019, the Department of Health of Ireland (DoH) and Health Service Executive (HSE) commissioned the technical support of researchers to develop an outcome-oriented HSPA framework which should reflect the shared priorities of multiple stakeholders, including citizens. This study describes the method applied in the Irish context and reflects on the added value of using a citizen panel in the development of an HSPA framework. METHODS: A panel of 15 citizens was convened, recruited by a third-party company using a sampling strategy to achieve a balanced mix representing the Irish society. Panellists received lay-language preparatory materials before the meeting. Panellists used a three-colour scheme to signal the importance of performance measures. An exit questionnaire was administered to understand how participants experienced being part of the panel. The citizen panel was the first in a series of three panels towards the development of the HSPA framework, followed by panels including representatives of the DoH and HSE, and representatives from professional associations and special interest groups. RESULTS: The citizen panel generated 249 health performance measures ranging across 13 domains. Top-ranking domains to the citizen panel (people-centredness, coordination of care, and coverage) were less prioritized by the other panels; domains less prioritized by the citizen panel, such as accessibility, responsiveness, efficiency, and effectiveness, were of higher priority in the other panels. Citizen panellists shared a similar understanding of what a citizen panel involves and described their experience at the panel as enjoyable, interesting, and informative. CONCLUSIONS: The priorities of the citizen panel were accounted for during all phases of developing the HSPA framework. This was possible by adopting an inclusive development process and by engaging citizens early on. Citizen engagement in HSPA development is essential for realizing citizen-driven healthcare system performance and generating trust and ownership in performance intelligence. Future research could expand the use of citizen panels to assess, monitor, and report on the performance of healthcare systems.

Development and Actionability of the Dutch COVID-19 Dashboard: Descriptive Assessment and Expert Appraisal Study.

BACKGROUND: Web-based public reporting by means of dashboards has become an essential tool for governments worldwide to monitor COVID-19 information and communicate it to the public. The actionability of such dashboards is determined by their fitness for purpose-meeting a specific information need-and fitness for use-placing the right information into the right hands at the right time and in a manner that can be understood. OBJECTIVE: The aim of this study was to identify specific areas where the actionability of the Dutch government's COVID-19 dashboard could be improved, with the ultimate goal of enhancing public understanding of the pandemic. METHODS: The study was conducted from February 2020 to April 2021. A mixed methods approach was carried out, using (1) a descriptive checklist over time to monitor changes made to the dashboard, (2) an actionability scoring of the dashboard to pinpoint areas for improvement, and (3) a reflection meeting with the dashboard development team to contextualize findings and discuss areas for improvement. RESULTS: The dashboard predominantly showed epidemiological information on COVID-19. It had been developed and adapted by adding more in-depth indicators, more geographic disaggregation options, and new indicator themes. It also changed in target audience from policy makers to the general public; thus, a homepage was added with the most important information, using news-like items to explain the provided indicators and conducting research to enhance public understanding of the dashboard. However, disaggregation options such as sex, socioeconomic status, and ethnicity and indicators on dual-track health system management and social and economic impact that have proven to give important insights in other countries are missing from the Dutch COVID-19 dashboard, limiting its actionability. CONCLUSIONS: The Dutch COVID-19 dashboard developed over time its fitness for purpose and use in terms of providing epidemiological information to the general public as a target audience. However, to strengthen the Dutch health system's ability to cope with upcoming phases of the COVID-19 pandemic or future public health emergencies, we advise (1) establishing timely indicators relating to health system capacity, (2) including relevant data disaggregation options (eg, sex, socioeconomic status), and (3) enabling interoperability between social, health, and economic data sources.

The current and potential uses of Electronic Medical Record (EMR) data for primary health care performance measurement in the Canadian context: a qualitative analysis.

BACKGROUND: Electronic Medical Records (EMRs) are a rich data source to measure and improve quality of care. As Canadian primary health care (PHC) EMRs mature, there is increasing potential use of EMR data for performance measurement. This study identifies and describes current uses of EMR data for performance measurement and considerations to further its potential in the Canadian context. METHODS: We applied a qualitative case study design and descriptive assessment in three phases, consulting multiple data sources including scientific and grey literature, system leaders (n = 41), and clinician/researchers (n = 20). Phases included a multimethod approach to identify initiatives using EMR data for performance measurement across Canadian jurisdictions; in-depth review of current initiatives identified from a healthcare performance intelligence lens; and triangulation and thematic analysis across data sources to explore considerations for advancing performance measurement uses of EMR data in the Canadian context. RESULTS: Six initiatives of EMR data use for performance measurement were identified: one multi-jurisdictional; five jurisdiction-specific in the provinces of British Columbia, Manitoba and Ontario. EMR data uses were predominately for micro-level PHC physician and team performance improvement, with some use for meso-level organization/network-wide improvement. Indicator sets varied in number, though shared emphasis on chronic disease management and prevention/screening and to a lesser extent medication management. Key considerations for governing, resourcing and implementing EMR data for performance measurement were identified. CONCLUSIONS: The extent of EMR data use for performance measurement varies across Canada. To further its potential, pan-Canadian data and privacy standards, performance intelligence competencies and renewed core PHC indicators should be prioritized. Experiences across countries, coupled with increasing momentum for performance measurement using real-world data, should be leveraged to avoid unnecessarily slow progress in Canada and abroad.

Exploring the actionability of healthcare performance indicators for quality of care: a qualitative analysis of the literature, expert opinion and user experience.

BACKGROUND: This study explores the meaning of actionable healthcare performance indicators for quality of care-related decisions. To do so, we analyse the constructs of fitness for purpose and fitness for use across healthcare systems and in practice based on the literature, expert opinion and user experience. METHODS: A multiphase qualitative study was undertaken. Phases included a literature review, a first round of one-on-one interviews with a panel of academics and thought leaders in the field (n=16), and a second round of interviews with real-world users of performance indicators (n=16). Thematic analysis was conducted between phases in order to triangulate findings in a stepwise process. RESULTS: Common uses of healthcare performance indicators were differentiated within micro-meso-macro contexts of healthcare systems. Each purpose of use signals different decision-making tasks, and in effect information needs. An indicator's fitness for use can be appraised by three clusters of considerations: methodological, contextual and managerial. Methodological considerations gauge an indicator's perceived importance, engagement potential, interpretability, standardisation, feasibility of remedial actions, alignment to care models and sensitivity to change. Information infrastructure, system governance, workforce capacity and learning culture were found as enabling contextual considerations. Managerial considerations influencing an indicator's use in practice were found to span the selection of indicators, data collection, analysis, display of results and delivery of information to decision-makers. CONCLUSION: The actionability of a healthcare performance indicator should be appraised by its alignment with the intended purpose of use beyond aggregate healthcare system levels, in combination with the extent to which methodological, contextual and managerial fitness for use considerations are met. Striking a better balance between the importance weighted to an indicator's statistical merits and emphasis put to its fitness for purpose and use is needed for indicators that are ultimately actionable for quality of care-related decision-making.

Improving performance intelligence for governing an integrated health and social care delivery network: a case study on the Amsterdam Noord district.

BACKGROUND: A guiding principle of a successful integrated health and social care delivery network is to establish a governance approach based on learning, grounded in a data and knowledge infrastructure. The 'Krijtmolen Alliantie' is a network of health and social care providers with the ambition to realize such a performance intelligence driven governance model in line with the Triple Aim. This study seeks to identify what performance intelligence is available and how it can be improved. METHODS: This case study was conducted in the district of Amsterdam Noord, the Netherlands, and employed 23 semi-structured interviews with stakeholders in health and social care, a feasibility analysis of available administrative data, and a reflection meeting with board members of the 'Krijtmolen Alliantie'. Information needs for performance intelligence by the stakeholders were mapped and a data landscape of the district covered by the network was drafted. Finally, in the reflection meeting with board members of the 'Krijtmolen Alliantie' the information needs and data landscape were aligned with governing needs, resulting in priority domains around which to strengthen the data infrastructure for governance of the integrated health and social care delivery network. RESULTS: The 'Krijtmolen Alliantie' encompasses a network of providers with a diverse range of catchment areas. There are indicators on population health and welfare, however they have limited actionability for providers due to a misalignment with their respective catchment areas. There is a barrier in data exchange between health and social care providers. It is difficult to construct one indicator for per capita cost in the Dutch health data infrastructure as health and social care are subdivided in financing siloes. Priority domains for improvement of performance intelligence for the 'Krijtmolen Alliantie' are: 1) Per capita and per patient cost data integration that would allow combined accountability through aligning financial incentives to facilitate integrated care, and 2) combined patient experience and outcome measures to reflect network quality of care and patient experience performance. CONCLUSION: Available performance intelligence lacks actionability for the governance of integrated care networks. Our recommendation is to align performance intelligence with the regional governance responsibilities of stakeholders for health and social care delivery.

Association of Postoperative Infections After Fractures With Long-term Income Among Adults.

Importance: Postoperative infections after a fracture exert tremendous costs on the health care system. However, the patient economic burden associated with a postoperative infection is unclear. Objective: To evaluate the association between a postoperative infection and long-term income among patients with surgically treated fractures. Design, Setting, and Participants: A retrospective cohort study linked academic trauma center data with Maryland tax records using inverse probability of treatment weighting to estimate between-group differences among 11 673 adults who underwent surgery to treat fractures of the extremities or pelvis between January 1, 2003, and December 31, 2016. Statistical analysis was performed from November 5, 2019, to August 30, 2020. Exposure: A postoperative infection within 1 year of injury. Main Outcomes and Measures: The primary outcome was the annual household income up to 6 years after injury. Household income incorporates multiple types of income, including wage earnings, taxable Social Security benefits, workers' compensation, and disability benefits. Secondary outcomes included individual earnings, Social Security benefits, unemployment benefits, and catastrophic income loss. Results: The study included 11 673 patients (7756 male patients [66.4%]; mean [SD] age, 45.2 [19.2] years) with a mean (SD) preinjury household income of $30 505 ($89 030). A total of 403 patients (3.5%) had a postoperative infection. Postoperative infections were associated with a $6080 annual decrease (95% CI, -$12 114 to -$47; P = .048) in household income in the 6 years after injury. Postoperative infections were associated with a 6.6% increase (95% CI, 4.9%-8.3%; P < .001) in the risk of catastrophic wage loss within 2 years of the fracture and were associated with a 45% increase in the odds of receiving Social Security benefits (odds ratio, 1.45; 95% CI, 1.25-1.68; P < .001). However, incurring a postoperative infection was not associated with an increase in the value of the Social Security benefits received. Conclusions and Relevance: This study suggests that postoperative infections have significant and sustained income-associated implications for patients who experience a fracture. Current Social Security mechanisms may not offset the decreased income.

Reporting health services research to a broader public: An exploration of inconsistencies and reporting inadequacies in societal publications.

INTRODUCTION: Little is known about the accuracy of societal publications (e.g. press releases, internet postings or professional journals) that are based on scientific work. This study investigates a) inconsistencies between scientific peer-reviewed health services research (HSR) publications and non-scientific societal publications and b) replication of reporting inadequacies from these scientific publications to corresponding societal publications. METHODS: A sample of HSR publications was drawn from 116 publications authored in 2016 by thirteen Dutch HSR institutions. Societal publications corresponding to scientific publications were identified through a systematic internet search. We conducted a qualitative, directed content analysis on societal publications derived from the scientific publications to assess both reporting inadequacies and determine inconsistencies. Descriptive frequencies were calculated for all variables. Odds ratios were used to investigate whether inconsistencies in societal publications were less likely when the first scientific author was involved. RESULTS: We identified 43 scientific and 156 societal publications. 94 societal publications (60.3%), (associated with 32 scientific publications (74.4%)) contained messages that were inconsistent with the scientific work. We found reporting inadequacies in 22 scientific publications (51.2%). In 45 societal publications (28.9%), we found replications of these reporting inadequacies. The likelihood of inconsistencies between scientific and societal publications did not differ when the latter explicitly involved the first scientific author, (OR = 1.44, CI: 0.76-2.74); were published on the institute's or funder's website, (OR = 1.32, CI: 0.57-3.06); published with no involvement of a scientific author, (OR = 0.52, CI: 0.25-1.07). CONCLUSION: To improve societal publications, one should examine both the consistency with scientific research publications and ways to prevent replication of scientific reporting inadequacies. HSR institutions, funders, and scientific and societal publication platforms should invest in a supportive publication culture to further incentivise the responsible and skilled involvement of researchers in writing both scientific and societal publications.

International comparison of pressure ulcer measures in long-term care facilities: Assessing the methodological robustness of 4 approaches to point prevalence measurement.

INTRODUCTION: Pressure ulcer indicators are among the most frequently used performance measures in long-term care settings. However, measurement systems vary and there is limited knowledge about the international comparability of different measurement systems. The aim of this analysis was to identify possible avenues for international comparisons of data on pressure ulcer prevalence among residents of long-term care facilities. MATERIAL AND METHODS: A descriptive analysis of the four point prevalence measurement systems programs used in 28 countries on three continents was performed. The criteria for the description and analysis were based on the scientific literature on criteria for indicator selection, on issues in international comparisons of data and on specific challenges of pressure ulcer measurements. RESULTS: The four measurement systems use a prevalence measure based on very similar numerator and denominator definitions. All four measurement systems also collect data on patient mobility. They differ in the pressure ulcer classifications used and the requirements for a head-to-toe resident examination. The regional or country representativeness of long-term care facilities also varies among the four measurement systems. CONCLUSIONS: Methodological differences among the point prevalence measurement systems are an important barrier to reliable comparisons of pressure ulcer prevalence data. The alignment of the methodologies may be improved by implementing changes to the study protocols, such as aligning the classification of pressure ulcers and requirements for a head-to-toe resident skin assessment. The effort required for each change varies. All these elements need to be considered by any initiative to facilitate international comparison and learning.

Analysis of Patient Income in the 5 Years Following a Fracture Treated Surgically.

Importance: Orthopedic injury is assumed to bear negative socioeconomic consequences. However, the magnitude and duration of a fracture's impact on patient income and social insurance benefits remain poorly quantified. Objective: To characterize the association between orthopedic injury and patient income using state tax records. Design, Setting, and Participants: This cohort study included adult patients surgically treated for an orthopedic fracture at a US academic trauma center from January 2003 through December 2014. Hospital data were linked to individual-level state tax records using a difference-in-differences analysis performed from November 2019 through August 2020. The control group comprised of data resampled from fracture patients at least 6 years prior to injury. Exposures: An operatively treated fracture of the appendicular skeleton. Main Outcomes and Measures: The primary outcome was individual annual earnings up to 5 years postinjury. Secondary outcomes included annual household income and US Social Security benefits for 5 years postinjury and catastrophic wage loss within 2 years of injury. Results: A total of 9997 fracture patients (mean [SD] age, 44.6 [18.9] years; 6725 [67.3%] men) to 34 570 prefracture control participants (mean [SD] age, 40.0 [20.5] years; 21 666 [62.7%] men). The median (interquartile range) of preinjury wage earnings was $16 847 ($0 to $52 221). The mean annual decline in individual earnings during the 5 years following injury was $9865 (95% CI, -$10 686 to -$8862). Annual household income declined by $5259 (95% CI, -$6337 to -$4181) over the same period. A fracture was associated with a $206 (95% CI, $147 to $265) mean annual increase in Social Security benefits in the 5 years after injury. An injury increased the risk of catastrophic wage loss by 11.6% (95% CI, 10.5% to 12.7%). Substantial relative income loss was observed in patients with preinjury earnings in the top 3 quartiles, but changes in income were negligible for patients with preinjury earnings in the bottom quartile (19%; 95% CI, -4% to 48%). Conclusions and Relevance: In this cohort study of patients surgically treated for an orthopedic fracture at a US academic trauma center, fractures were associated with substantial individual and household income loss up to 5 years after injury, and 1 in 5 patients sustained catastrophic income loss in the 2 years after fracture. Gains in Social Security benefits offset less than 10% of annual income losses.

Exploring general practitioners' perceptions about the primary care gatekeeper role in Indonesia.

BACKGROUND: In the current healthcare delivery system funded by National Health Insurance (NHI) in Indonesia, the gatekeeper role of primary care services is critical to ensuring equal healthcare access for the population. To be effective, gatekeeping relies on the performance of general practitioners (GPs). However, the perceptions held by Indonesian GPs about their gatekeeper role are not yet well documented. This study describes the self-perceived knowledge, attitudes and performance of Indonesian GPs with respect to the gatekeeper role and explores associated factors. METHODS: We conducted a cross-sectional study of all primary care facilities (N = 75) contracted by the regional NHI office in the Banyumas district. The 73 participating GPs completed a written questionnaire that assessed their knowledge, attitudes and performance in relation to the gatekeeper role. Personal and facility characteristics were analysed in a generalised linear model as possible associating factors, as well as for the association between GPs' knowledge and attitude with performance as gatekeepers. RESULTS: GPs scored relatively high in the domains of knowledge and performance but scored lower in their attitudes towards the gatekeeper role of primary care. In the full-adjusted model, no factors were significantly associated with the knowledge score. Work experience as GPs, private or civil service employment status and rural or urban location of the primary care facility were linked to attitude scores. Full- or part-time employment and type of facility were factors associated with the performance score. Attitude scores were positively associated with performance score. CONCLUSION: GPs in Indonesia are knowledgeable and report that they adequately perform their function as gatekeepers in primary care. However, their attitudes towards the gatekeeper function are less positive. Attitudes and performance with respect to the primary care gatekeeper role are likely influenced more by contextual factors such as location and type of facility than by personal factors. Efforts to address contextual issues could include improvements in practice standards for privately practising physicians and public information campaigns about gatekeeping regulations. Such efforts will be crucial to improving the gatekeeper role of primary care in Indonesia and assuring efficient access to high-quality care for all.

Patients Place More of an Emphasis on Physical Recovery Than Return to Work or Financial Recovery.

BACKGROUND: Value-based healthcare models aim to incentivize healthcare providers to offer interventions that address determinants of health. Understanding patient priorities for physical and socioeconomic recovery after injury can help determine which services and resources are most useful to patients. QUESTIONS/PURPOSES: (1) Do trauma patients consistently identify a specific aspect/domain of recovery as being most important at 6 weeks, 6 months, and 12 months after an injury? (2) Does the relative importance of those domains change within the first year after injury? (3) Are differences in priorities greater between patients than for a given patient over time? (4) Are different recovery priorities associated with identifiable biopsychosocial factors? METHODS: Between June 2018 and December 2018, 504 adult patients with fractures of the extremities or pelvis were surgically treated at the study site. For this prospective longitudinal study, we purposefully sampled patients from 6 of the 12 orthopaedic attendings' postoperative clinics. The participating surgeons surgically treated 243 adult patients with fractures of the extremities or pelvis. Five percent (11 of 243) of patients met inclusion criteria but missed their appointments during the 6-week recruitment window and could not be consented. We excluded 4% (9 of 243) of patients with a traumatic brain injury, 1% (2) of patients with a spinal cord injury, and 5% (12) of non-English-speaking patients (4% Spanish speaking [10]; 1% other languages [2]). Eighty-six percent of eligible patients (209 of 243) were approached for consent, and 5% (11 of 209) of those patients refused to participate. All remaining 198 patients consented and completed the baseline survey; 83% (164 of 198 patients) completed at least 6 months of follow-up, and 68% (134 of 198 patients) completed the 12-month assessment. The study participants' mean age was 44 ± 17 years, and 63% (125 of 198) were men. The primary outcome was the patient's recovery priorities, assessed at 6 weeks, 6 months, and 12 months after fracture using a discrete choice experiment. Discrete choice experiments are a well-established method for eliciting decisional preferences. In this technique, respondents are presented with a series of hypothetical scenarios, described by a set of plausible attributes or outcomes, and asked to select their preferred scenario. We used hierarchical Bayesian modeling to calculate individual-level estimates of the relative importance of physical recovery, work-related recovery, and disability benefits, based on the discrete choice experiment responses. The hierarchical Bayesian model improves upon more commonly used regression techniques by accounting for the observed response patterns of individual patients and the sequence of scenarios presented in the discrete choice experiment when calculating the model estimates. We computed the coefficient of variation for the three recovery domains and compared the between-patient versus within-patient differences using asymptotic tests. Separate prognostic models were fit for each of the study's three recovery domains to assess marginal changes in the importance of the recovery domain based on patient characteristics and factors that remained constant over the study (such as sex or preinjury work status) and patient characteristics and factors that varied over the study (including current work status or patient-reported health status). We previously published the 6-week results. This paper expands upon the prior publication to evaluate longitudinal changes in patient recovery priorities. RESULTS: Physical recovery was the respondents' main priority at all three timepoints, representing 60% ± 9% of their overall concern. Work-related recovery and access to disability benefits were of secondary importance and were associated with 27% ± 6% and 13% ± 7% of the patients' concern, respectively. The patients' concern for physical recovery was 6% (95% CrI 4% to 7%) higher at 12 months after fracture that at 6 weeks postfracture. The mean concern for work-related recovery increased by 7% (95% CrI 6% to 8%) from 6 weeks to 6 months after injury. The mean importance of disability benefits increased by 2% (95% CrI 1% to 4%) from 6 weeks to 6 months and remained 2% higher (95% CrI 0% to 3%) at 12 months after the injury. Differences in priorities were greater within a given patient over time than between patients as measured using the coefficient of variation (physical recovery [245% versus 7%; p < 0.001], work-related recovery [678% versus 12%; p < 0.001], and disability benefits [620% versus 33%; p < 0.001]. There was limited evidence that biopsychosocial factors were associated with variation in recovery priorities. Patients' concern for physical recovery was 2% higher for every 10-point increase in their Patient-reported Outcome Measure Information System (PROMIS) physical health status score (95% CrI 1% to 3%). A 10-point increase in the patient's PROMIS mental health status score was associated with a 1% increase in concern for work-related recovery (95% CrI 0% to 2%). CONCLUSION: Work-related recovery and accessing disability benefits were a secondary concern compared with physical recovery in the 12 months after injury for patients with fractures. However, the importance of work-related recovery was elevated after the subacute phase. Priorities were highly variable within a given patient in the year after injury compared with between-patient differences. Given this variation, orthopaedic surgeons should consider assessing and reassessing the socioeconomic well-being of their patients throughout their continuum of care. LEVEL OF EVIDENCE: Level II, therapeutic study.

The contribution of service density and proximity to geographical inequalities in health care utilisation in Indonesia: A nation-wide multilevel analysis.

BACKGROUND: Geographical inequalities in access to health care have only recently become a global health issue. Little evidence is available about their determinants. This study investigates the associations of service density and service proximity with health care utilisation in Indonesia and the parts they may play in geographic inequalities in health care use. METHODS: Using data from a nationally representative survey (N = 649 625), we conducted a cross-sectional study and employed multilevel logistic regression to assess whether supply-side factors relating to service density and service proximity affect the variability of outpatient and inpatient care utilisation across 497 Indonesian districts. We used median odds ratios (MORs) to estimate the extent of geographical inequalities. Changes in the MOR values indicated the role played by the supply-side factors in the inequalities. RESULTS: Wide variations in the density and proximity of health care services were observed between districts. Outpatient care utilisation was associated with travel costs (odds ratio (OR) = 0.82, 95% confidence interval (CI) = 0.70-0.97). Inpatient care utilisation was associated with ratios of hospital beds to district population (OR = 1.23, 95% CI = 1.05-1.43) and with travel times (OR = 0.72 95% CI = 0.61-0.86). All in all, service density and proximity provided little explanation for district-level geographic inequalities in either outpatient (MOR = 1.65, 95% CrI = 1.59-1.70 decreasing to 1.61, 95% CrI = 1.56-1.67) or inpatient care utilisation (MOR = 1.63, 95% CrI = 1.55-1.69 decreasing to 1.60 95% CrI = 1.54-1.66). CONCLUSIONS: Supply-side factors play important roles in individual health care utilisation but do not explain geographical inequalities. Variations in other factors, such as the price and responsiveness of services, may also contribute to the inequalities. Further efforts to address geographical inequalities in health care should go beyond the physical presence of health care infrastructures to target issues such as regional variations in the prices and responsiveness of services.

Individual, institutional, and scientific environment factors associated with questionable research practices in the reporting of messages and conclusions in scientific health services research publications.

BACKGROUND: Health Services Research findings (HSR) reported in scientific publications may become part of the decision-making process on healthcare. This study aimed to explore associations between researcher's individual, institutional, and scientific environment factors and the occurrence of questionable research practices (QRPs) in the reporting of messages and conclusions in scientific HSR publications. METHODS: We employed a mixed-methods study design. We identified factors possibly contributing to QRPs in the reporting of messages and conclusions through a literature review, 14 semi-structured interviews with HSR institutional leaders, and 13 focus-groups amongst researchers. A survey corresponding with these factors was developed and shared with 172 authors of 116 scientific HSR publications produced by Dutch research institutes in 2016. We assessed the included publications for the occurrence of QRPs. An exploratory factor analysis was conducted to identify factors within individual, institutional, and environmental domains. Next, we conducted bivariate analyses using simple Poisson regression to explore factors' association with the number of QRPs in the assessed HSR publications. Factors related to QRPs with a p-value < .30 were included in four multivariate models tested through a multiple Poisson regression. RESULTS: In total, 78 (45%) participants completed the survey (51.3% first authors and 48.7% last authors). Twelve factors were included in the multivariate analyses. In all four multivariate models, a higher score of "pressure to create societal impact" (Exp B = 1.28, 95% CI [1.11, 1.47]), was associated with higher number of QRPs. Higher scores on "specific training" (Exp B = 0.85, 95% CI [0.77-0.94]) and "co-author conflict of interest" (Exp B = 0.85, 95% CI [0.75-0.97]) factors were associated with a lower number of QRPs. Stratification between first and last authors indicated different factors were related to the occurrence of QRPs for these groups. CONCLUSION: Experienced pressure to create societal impact is associated with more QRPs in the reporting of messages and conclusions in HSR publications. Specific training in reporting messages and conclusions and awareness of co-author conflict of interests are related to fewer QRPs. Our results should stimulate awareness within the field of HSR internationally on opportunities to better support reporting in scientific HSR publications.