Beyond accreditation: a multi-track quality-enhancing strategy for primary health care in low- and middle-income countries.

Many define an equitable health care system as one that provides logistical and financial access to "quality" care to the population. Realizing that fact, many low- and middle-income countries started investing in enhancing the quality of care in their health care systems, recently in primary health care. Unfortunately, in many instance, these investments have been exclusively focused on accreditation due to available guidelines and existing accrediting structures. A multi-track quality-enhancing strategy (MTQES) is proposed that includes, in addition to promoting resource-sensitive accreditation, other quality initiatives such as clinical guidelines, performance indicators, benchmarking activities, annual quality-enhancing projects, and annual quality summit/meeting. These complementary approaches are presented to synergistically enhance a continuous quality improvement culture in the primary health care sector, taking into consideration limited resources available, especially in low- and middle-income countries. In addition, an implementation framework depicting MTQES in three-phase interlinked packages is presented; each matches existing resources and quality infrastructure. Health care policymakers and managers need to think about accreditation as a beginning rather than an end to their quest for quality. Improvements in the structure of a health delivery organization or in the processes of care have little value if they do not translate to reduced disparities in access to "quality" care, and not merely access to care.

The path towards universal health coverage in the Arab uprising countries Tunisia, Egypt, Libya, and Yemen.

The constitutions of many countries in the Arab world clearly highlight the role of governments in guaranteeing provision of health care as a right for all citizens. However, citizens still have inequitable health-care systems. One component of such inequity relates to restricted financial access to health-care services. The recent uprisings in the Arab world, commonly referred to as the Arab spring, created a sociopolitical momentum that should be used to achieve universal health coverage (UHC). At present, many countries of the Arab spring are considering health coverage as a priority in dialogues for new constitutions and national policy agendas. UHC is also the focus of advocacy campaigns of a number of non-governmental organisations and media outlets. As part of the health in the Arab world Series in The Lancet, this report has three overarching objectives. First, we present selected experiences of other countries that had similar social and political changes, and how these events affected their path towards UHC. Second, we present a brief overview of the development of health-care systems in the Arab world with regard to health-care coverage and financing, with a focus on Egypt, Libya, Tunisia, and Yemen. Third, we aim to integrate historical lessons with present contexts in a roadmap for action that addresses the challenges and opportunities for progression towards UHC.

Accreditation of hospitals in Lebanon: is it a worthy investment?

OBJECTIVE: This study explores the views of Lebanese hospitals on the worthiness of accreditation vis-à-vis its associated expenses in addition to examining the type and source of financial investments incurred during the accreditation process. DESIGN: Observational cross-sectional design. PARTICIPANTS: All private short-stay hospitals registered with the Syndicate of Private Hospitals in Lebanon (110 hospitals). MAIN OUTCOME MEASURE: Hospital's views on the worthiness of accreditation in lieu of its associated expenses. Other measures explored included areas of expenditure increase and sources of expenses coverage for accreditation. RESULTS: Three-fifths of responding hospitals (63% response rate) considered accreditation as a worthy investment. Favorable views on accreditation were mostly related to its effect on enhanced quality and safety culture. Unfavorable views regarding the worthiness of accreditation investment were justified by absence of link with enhanced tariffs from payers (25.7%). All hospitals incurred increased expenses due to accreditation. Areas of highest increase included training of staff (95.7%), consultants' costs (80.0%) and infrastructure maintenance (77.1%). Most of the hospitals covered expenses through internal absorption (52%) or bank loans (45.7%). CONCLUSIONS: The financial burden of accreditation on hospitals has to be factored in the decision of its adoption at a national level, especially in developing countries.

Acceptability of quality reporting and pay for performance among primary health centers in Lebanon.

Primary health care (PHC) is emphasized as the cornerstone of any health care system. Enhancing PHC performance is considered a strategy to enhance effective and equitable access to care. This study assesses the acceptability of and factors associated with quality reporting among PHC centers (PHCCs) in Lebanon. The managers of 132 Lebanese Ministry of Health PHCCs were surveyed using a cross-sectional design. Managers' willingness to report quality, participate in comparative quality assessments, and endorse pay-for-performance schemes was evaluated. Collected data were matched to the infrastructural characteristics and services database. Seventy-six percent of managers responded to the questionnaire, 93 percent of whom were willing to report clinical performance. Most expressed strong support for peer-performance comparison and pay-for-performance schemes. Willingness to report was negatively associated with the religious affiliation of centers and presence of health care facilities in the catchment area and favorably associated with use of information systems and the size of population served. The great willingness of PHCC managers to employ quality-enhancing initiatives flags a policy priority for PHC stakeholders to strengthen PHCC infrastructure and to enable reporting in an easy, standardized, and systematic way. Enhancing equity necessitates education and empowerment of managers in remote areas and those managing religiously affiliated centers.

An effectiveness and cost-benefit analysis of a hospital-based discharge transition program for elderly Medicare recipients.

OBJECTIVE: To investigate the business case of postdischarge care transition (PDCT) among Medicare beneficiaries by conducting a cost-benefit analysis. DESIGN: Randomized controlled trial. SETTING: A general hospital in upstate New York State. PARTICIPANTS: Elderly Medicare beneficiaries being treated from October 2008 through December 2009 were randomly selected to receive services as part of a comprehensive PDCT program (intervention--173 patients) or regular discharge process (control--160 patients) and followed for 12 months. INTERVENTION: The intervention comprised five activities: development of a patient-centered health record, a structured discharge preparation checklist of critical activities, delivery of patient self-activation and management sessions, follow-up appointments, and coordination of data flow. MEASUREMENTS: Cost-benefit ratio of the PDCT program; self-management skills and abilities. RESULTS: The 1-year readmission analysis revealed that control participants were more likely to be readmitted than intervention participants (58.2% vs 48.2%; P = .08); with most of that difference observed in the 91 to 365 days after discharge. Findings from the cost-benefit analysis revealed a cost-benefit ratio of 1.09, which indicates that, for every $1 spent on the program, a saving of $1.09 was realized. In addition, participating in a care transition program significantly enhanced self-management skills and abilities. CONCLUSION: Postdischarge care transition programs have a dual benefit of enhancing elderly adults' self-management skills and abilities and producing cost savings. This study builds a case for the inclusion of PDCT programs as a reimbursable service in benefit packages.

The effectiveness and cost-effectiveness of a rural employer-based wellness program.

CONTEXT: The cost-effectiveness of employer-based wellness programs has been previously investigated with favorable financial and nonfinancial outcomes being detected. However, these investigations have mainly focused on large employers in urban settings. Very few studies examined wellness programs offered in rural settings. PURPOSE: This paper aims to explore the effectiveness and cost-effectiveness of a rural employer-based wellness program. METHODS: Six rural employers were categorized into 3 groups: a control group and 2 intervention groups with varying degrees of wellness activities. Participants were asked to complete an annual health risk assessment (HRA) that addressed 16 wellness areas. At the conclusion of 4 years, HRA and effectiveness data were utilized to examine program effectiveness and combined with program costs to estimate cost-effectiveness. FINDINGS: The "Coaching and Referral" group-the highest in intensity of participant engagement-exhibited superior improvement in several wellness areas and in percentage of employees with good health indicators compared to the control and the Trail Marker, lower-intensity intervention groups. However, the Trail Markers had more favorable cost-effectiveness ratios. CONCLUSIONS: Rural worksite wellness programs have shown great potential in their effectiveness and cost-effectiveness. Such programs need not be too aggressive, tedious, and costly to generate a favorable return for employers and funders. However, employers should be encouraged to experiment with different levels of wellness program intensities until a more favorable outcome can be realized.

The cost impact of hospital-acquired conditions among critical care patients.

BACKGROUND: The modifications introduced to the inpatient prospective payment system on October 1, 2008, to disallow payment for 8 secondary conditions, if not present on admission (POA), constitute a significant shift that is expected to be followed by similar steps by private payers. OBJECTIVE: To investigate the cost impact of hospital-acquired complications (HACs). RESEARCH DESIGN: Discharges that included critical care (CC) stay cases, stratified by diagnosis-related groups, were categorized into (1) cases with HACs-those cases where 1 or more of complications were acquired during the course of treatment; (2) cases with complications that were POA; and (3) cases with no HACs or complications on admission. Twelve diagnostic condition groupings or HACs were examined. RESULTS: Sepsis was the most common condition among single-occurrence HACs, as well as those where 2 HACs occurred. Among the 22 diagnosis-related groups examined, total discharge and CC costs, length of stay, and CC length of stay were consistently the highest among discharges where a HAC occurred, followed by discharges with the presence of a POA complication. Conversely, the lowest level of resource use was associated with discharges where no complication occurred. CONCLUSIONS: The estimates provided in this study should enable hospitals to identify how improvements in care can also result in cost savings. Focusing this study on CC cases enables hospitals to address highest cost cases that consume crucial resources in their CC settings.

The case for developing publicly-accessible datasets for health services research in the Middle East and North Africa (MENA) region.

BACKGROUND: The existence of publicly-accessible datasets comprised a significant opportunity for health services research to evolve into a science that supports health policy making and evaluation, proper inter- and intra-organizational decisions and optimal clinical interventions. This paper investigated the role of publicly-accessible datasets in the enhancement of health care systems in the developed world and highlighted the importance of their wide existence and use in the Middle East and North Africa (MENA) region. DISCUSSION: A search was conducted to explore the availability of publicly-accessible datasets in the MENA region. Although datasets were found in most countries in the region, those were limited in terms of their relevance, quality and public-accessibility. With rare exceptions, publicly-accessible datasets - as present in the developed world - were absent. Based on this, we proposed a gradual approach and a set of recommendations to promote the development and use of publicly-accessible datasets in the region. These recommendations target potential actions by governments, researchers, policy makers and international organizations. SUMMARY: We argue that the limited number of publicly-accessible datasets in the MENA region represents a lost opportunity for the evidence-based advancement of health systems in the region. The availability and use of publicly-accessible datasets would encourage policy makers in this region to base their decisions on solid representative data and not on estimates or small-scale studies; researchers would be able to exercise their expertise in a meaningful manner to both, policy makers and the public. The population of the MENA countries would exercise the right to benefit from locally- or regionally-based studies, versus imported and in 'best cases' customized ones. Furthermore, on a macro scale, the availability of regionally comparable publicly-accessible datasets would allow for the exploration of regional variations and benchmarking studies.

The effect of preoperative and hospital characteristics on costs for coronary artery bypass graft.

OBJECTIVE: This study aimed at exploring the effect of preoperative risk factors and hospital characteristics on costs of coronary artery bypass graft (CABG) hospitalizations. BACKGROUND: The considerable investment in hospital-based cardiac programs has not been coupled with comparable efforts to explore cost drivers of associated procedures. METHODS: Data sources included (a) New York State's Cardiac Surgery Reporting System, (b) New York State's Statewide Planning and Research Cooperative System dataset, (c) American Hospital Association dataset, and (d) Medicare Hospital Cost Report Public Use files and wage index files. The study population comprised New York state residents who underwent an isolated CABG procedure in a New York State hospital and were discharged in 2003. The outcome measure was inpatient costs. Independent variables included patient (demographic and clinical) and hospital characteristics. RESULTS: The total number of cases was 12,016. Findings revealed that selected demographic characteristics, including older age, female gender, and being black, were associated with higher costs. Several clinical characteristics were found to affect CABG discharge costs such as lower ejection fraction, the duration between CABG admission and the occurrence of myocardial infarction, number of diseased vessels, previous open heart operations, and a number of comorbidities. Furthermore, larger hospitals were associated with higher CABG discharge costs, while costs significantly decreased with higher CABG volume. CONCLUSIONS: Hospitals should explore ways to address patient (patient management) and hospital (case volume), when possible, associated with higher CABG discharge costs in its efforts to contain costs.

Patterns and associated health services costs of antihypertensive drug modifications.

This study sought to identify patterns of antihypertensive drug modifications in initial drug therapy as well as to examine the effect of modifications on costs. The study population included adults who initiated antihypertensive drug therapy during 12 months of therapy. Approximately three-fourths of study participants had a change in therapy within the first 12 months of treatment. Discontinuation (57.1%) of antihypertensive drug treatment was the most prevalent modification type, followed by titrations (14.6%). Initiating treatment with fixed-dose combinations was associated with the lowest likelihood of a nondiscontinuation modification (12.5%); the use of 2 separate drugs was associated with the least likelihood of complete discontinuation (28.7%). The presence of therapy changes was associated with increased health services costs in the first 12 months of antihypertensive drug therapy. Clinicians and payers should be aware of the association between starting specific antihypertensive treatment regimens and the likelihood of changes in medication and changing costs.

Identifying Centers of Excellence in Efficiency and Quality in coronary revascularization: an exploratory approach for procedure-specific value-based purchasing program design.

The advent of the value-based purchasing (VBP) concept in which efficiency and quality are considered prompted an interest in exploring approaches that incorporate both. This study examined a hospital classification method, Centers for Excellence in Efficiency and Quality (CEEQs), for coronary revascularization procedures. The results identified select hospitals (two [out of 33] in coronary artery bypass graft surgery (CABG) and seven in percutaneous coronary intervention (PCI)) that can be classified as CEEQs. Furthermore, an investigation of hospitals' efficiency and quality revealed great variation in efficiency among high-quality hospitals. The study demonstrated the possibility of employing service- or disease-specific approaches to VBP and pay-for-performance (P4P) programs.

The effect of insurance type on prescription drug use and expenditures among elderly Medicare beneficiaries.

The debate over the impact of the new Medicare prescription drug benefit (Part D) has intensified in anticipation of its implementation. This paper contributes additional information related to the effect of different types of prescription drug coverage plans on use and expenditures among elderly Medicare beneficiaries. Cross-sectional design using data from the 2002 Medical Expenditures Panel Survey (MEPS). The two dependent variables were (1) prescription drug use and (2) expenditures. The main independent variable was the type of drug insurance (Medicare FFS only [no Rx insurance], Medicare FFS + Rx insurance and Medicare HMO). Bivariate and multivariate analyses were used to test the effect of insurance type, and beneficiaries' characteristics, on likelihood and level of drug use, as well as expenditures. The findings showed that average total drug expenditures among Medicare FFS enrollees who had Rx insurance (non-HMO) were higher ($182.51) than that of Medicare FFS enrollees with no Rx insurance. In addition, the former group had a higher likelihood (any use) of using prescribed medications. On the other hand, no differences in the likelihood of use were detected between Medicare HMO and Medicare FFS (no Rx insurance) enrollees. However, Medicare HMO enrollees had a higher level of drug use. In conclusion, The differences in drug use and expenditures by insurance type imply that each party (Medicare, Medicare Advantage plans, employers) will have a different set of disincentives for involvement in Medicare Part D.

Another evolvement of the cost and risk shifting model: consumer-driven health plans.

The US health care system has changed dramatically over the past forty years or so. This paper analyzes its potential transformation into a consumer-driven health care system (with the newly enacted HSAs and the increased popularity of employer defined contributions). The emphasis in the first part is the evolution of the role of providers (mostly physicians) into bearers of financial risk and gatekeepers. The second part discusses the new consumer-driven health care proposals and its potential impact on the future of health care as it pertains to putting consumers under financial risk and gives them a perceived sense of control over health care decisions.

Trends in Medicare disproportionate share (DSH) distribution in US hospitals: 1996-2003.

Implemented in 1986, Medicare's disproportionate share (DSH) adjustment is intended to recognize hospitals' additional resource investment in caring for low-income patients. This project analyzed changes in the DSH percentage between 1996 and 2003 and examined the association between selected hospital characteristics and such changes. Results obtained revealed some interesting findings. First, minimal changes in DSH percentage occurred during the period 1996-1999 with a hike in that ratio in 2000-2001. However, even with the absence of any legislative or executive changes to the DSH threshold or formula during 2002 and 2003, significant increases occurred during 2001-2003 (11 percent increase between 2001 and 2003). Such an increase may be caused by the nation's economic situation during that timeframe (i.e., more people depending on public programs for coverage).

Resource use of elderly emergency department patients with alcohol-related diagnoses.

This study evaluates resource use associated with alcohol-related admissions through the emergency department (ED) by older adults. Data from 11 states were extracted from the Healthcare Cost and Utilization Project State Inpatient Databases. The study results revealed that the presence of a secondary alcohol-related diagnosis significantly increased resource use (37-119% for length of stay and 126-343% for charges; p < .05) associated with the top 10 International Classification of Diseases, Ninth Revision, Clinical Modification Clinical Classifications Software diagnoses. They also showed that admissions with an alcohol-related primary diagnosis had lower associated charges (2,172 dollars; p < .05) and longer lengths of stay (0.3 days; p < .05) than other types of ED admissions. Proper linkages to substance abuse treatment services should be instituted and coupled with medical treatment to limit the additional resource use burden of alcohol-related admissions.

A multistate comparison of patient characteristics, outcomes, and treatment practices in acute myocardial infarction.

The primary purpose of this study was to examine variations in patient characteristics, outcomes, and treatment practices in acute myocardial infarction (AMI) across 11 states. Data from 11 states were extracted from the Healthcare Cost and Utilization Project State Inpatient Dataset. Patients who had a primary diagnosis of AMI (International Classification of Diseases, Ninth Revision, Clinical Modification, code 410.x1) from 11 states were extracted from the Healthcare Cost and Utilization Project 1999 dataset. Bivariate comparisons were conducted to examine the characteristics, treatment practices, and outcomes of patients who had AMI. Multivariate regression models were used to examine the association between geographic location (and other factors) and the likelihood of in-hospital mortality, undergoing coronary artery bypass grafting (CABG), or percutaneous coronary interventions (PCIs). Results revealed considerable variations across states in practice patterns and treatment outcomes. New York had the highest average length of stay (8.2 days, p <0.01), rate of patients who had AMI being transferred (20.7%, p <0.01), and in-hospital case fatality rate (10.7%, p <0.01) and the lowest rate of alive discharges being routine (65.6%, p <0.01). PCI was performed 2 times as often as CABG for patients who had AMI (23.9% vs 11.3%, p <0.01), with patients who underwent CABG being transferred more often. Multivariate analyses showed that state of residence, age, female gender, transfer status, and number of co-morbidities were predictors of in-hospital mortality and the likelihood of undergoing CABG or PCI. In conclusion, large differences in practice patterns and treatment outcomes exist across states.

Evaluating the effectiveness of public health leadership training: the NEPHLI experience.

OBJECTIVES: We assessed the effect of public health leadership training on the capacity of public health leaders to perform competencies derived from the list of "Ten Essential Public Health Services" presented in 1994 by the steering committee of the Public Health Functions Project. METHODS: Graduating scholars of the Northeast Public Health Leadership Institute were surveyed to determine differences in skill level in 15 competency areas before and after training. Surveys were completed after program completion. RESULTS: The training program improved the skill levels of participants in all 15 competency areas. A relation also was detected between the frequency of use of the competency and the improvement experienced. CONCLUSIONS: Public health leadership training programs are effective in improving the skills of public health workers.

Carotid endarterectomy utilization and mortality in 10 states.

BACKGROUND: Studies that examined the rates of and mortality after carotid endarterectomy (CEA) mainly were confined to a limited geographical location or population. The primary purposes of this study are to examine the variation of risk-adjusted in-hospital mortality rates after CEA in 10 states, and utilization rates per capita of CEA. METHODS: An analysis was made of hospital discharge data from 10 states extracted from the Agency for Health Research and Quality national database, Healthcare Cost and Utilization Project (HCUP). RESULTS: The rates of CEA per capita were found to differ among the 10 states examined. No significant association was detected between geographic location and the adjusted risk of in-hospital mortality. Sex, age, type of admission, and several comorbidities were found to be significant risk factors. CONCLUSIONS: Rates of CEA per capita differ among states. However, geographical location does not affect the likelihood of risk-adjusted mortality after the procedure.

The effect of case management in substance abuse on health services use.

This study evaluated the effect of case management, as a supplement to traditional substance abuse treatment, on health services utilization. Data for the study were taken from the Iowa Case Management Project (ICMP). The ICMP evaluated case management using a randomized research design. Residential clients who agreed to participate were randomly assigned to one of four case management conditions. The first three conditions were variations of the Iowa Case Management (ICM) model: (a) Inside Case Management, (b) Outside Case Management, and (c) Telecommunications. Case management clients in these three conditions were eligible for 12 months of case management. The fourth condition, the control condition, received no additional case management through ICMP. The study results show that the use of case management decreased the use of mental health services while increasing clients' use of inpatient care, access to physician, and the emergency room. It was expected that case management would increase, in the short run, the substance abuser's use of health services due to staying longer in treatment and seeking medical care that would be otherwise neglected. However, in the long run such early use of necessary health services might reduce the clients' use of avoidable, more costly care. Case management should be looked at as an investment with long-term payoffs.