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  1. Tom Smith

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    This journal scan is based on an electronic search of clinical and organisational databases. The abstracts are from papers and articles published in the period between June and August 2001. As a complex organisational sector, health care attracts the interest of a wide range of disciplines and hundreds of non-clinical journals publish articles associated with health and quality. The following abstracts offer a mixture of clinical and other insights. For example, marketing specialists explore the reactions of a key target group to health messages aimed at them and an economist writes on the motivations of nurses. The interest of other disciplines in quality provides a wide source of information; the aim of these pages is to provide a taster of what is being written about and read by people interested in the quality of health care.

    Nurse recruitment and retention

    Several articles in the USA and UK this quarter are concerned with the shortage of nurses and the impact on healthcare quality.

    Nursing shortage puts patients at risk and creates liability problems. Healthcare Risk Management 2001;23:61–7.

    Nurse shortages have far reaching implications for quality of health care. Nurses working in US hospitals suffer stress from the problems in their work associated with the shortage. Research shows that a significant percentage of nurses are planning to leave their career. The article is a discussion of the factors that may influence the decision of nurses to stay in the field. This is a major issue for hospital employers concerned at the knock on effects for the quality of nursing services as a whole and of potential liability issues related to staffing shortages.

    HHS awards $27.4 million to address emerging nursing shortage. Press Release. US Department of Health and Human Services, 28 September 2001.

    HHS Secretary Tommy G Thompson announced more than $27.4 million to increase the number of qualified nurses and the quality of nursing services across the country. The awards will help to ease the emerging shortage of qualified nurses available to provide essential healthcare services in many communities nationwide. “As the demand for health care grows, it's absolutely critical that we encourage more of our nation's top students to choose careers in nursing,” Secretary Thompson said. 94 grants will be awarded to 82 colleges, universities and other organisations to increase the number of nurses with bachelor's and advanced degrees, to help diversify the nurse workforce, and to prepare more nurses to serve in public health leadership roles.

    Shields MA, Ward M. Improving nurse retention in the National Health Service in England: the impact of job satisfaction. J Health Econ 2001;20:677–701.

    Abstract reproduced from original

    In recent years the British National Health Service (NHS) has experienced an acute shortage of qualified nurses. The importance of job satisfaction in determining nurses' intentions to quit the NHS is established. Nurses who report overall dissatisfaction with their jobs have a 65% higher probability of intending to quit than those reported to be satisfied. However, dissatisfaction with promotion and training opportunities are found to have a stronger impact than workload or pay.

    Health care information and technology

    If information systems are to have an impact on quality, it is important that they are an integral part of working rather than a post event system for collecting data. Among other articles in a special issue of Health Affairs, one looks at five conditions and asks whether technological advances have been worth the cost, and another looks at the cost benefits of breakthrough medicines. For patients, innovations in procedures rather than in medication are more important, according to their physicians.

    Boone T, Ganeshan R. The effect of information technology on learning in professional service organizations. J Operations Manage 2001;19:485–95.

    Abstract reproduced from original

    This study examines the relationship between organizational experience and productivity in a professional service organization. The research addresses a gap in the existing literature with respect to organizational experience models in service organizations. Findings confirm a significant, positive relationship between organizational experience and productivity. In addition, the effect of information technology on the relationship between organizational experience and productivity is investigated. The findings indicate that information technology that becomes a part of the production process is associated with productivity improvements, while information technology that merely documents or collects information is not.

    Cutler DM, McClellan M. Is technological change in medicine worth it? Health Aff 2001;20:11–29.

    Abstract reproduced from original

    Medical technology is valuable if the benefits of medical advances exceed the costs. The technological change in five conditions is analysed to determine if this is so. In four of the conditions—heart attacks, low birth weight infants, depression, and cataracts—the estimated benefit of technological change is much greater than the cost. In the fifth condition, breast cancer, costs and benefits are about of equal magnitude. It is concluded that medical spending as a whole is worth the increased cost of care. This has many implications for public policy.

    Kleinke JD. The price of progress: prescription drugs in the health care market. Health Aff 2001;20:43–51.

    Abstract reproduced from original

    Pharmacy costs are rising in excess of general and medical cost inflation, leading to calls for price and utilization controls by public and private players. Such controls would be ineffective and counterproductive because they would attempt to reverse two profound, historic phenomena at work in the US health care system. The added costs associated with breakthrough medicines represent a major structural shift from the provision of traditional medical services to the consumption of medical products; they also represent the creation of economic, social, and public health utility that the society values. Federal and state laws regulating health insurance and provider risk sharing need to be revamped to encourage rather than constrain the social progress embodied in expensive breakthrough medical technologies.

    Fuchs VR, Sox HC Jr. Physicians' views of the relative importance of thirty medical innovations. Health Aff 2001;20:30–42.

    Abstract reproduced from original

    In response to a mail survey, 225 leading general internists provided their opinions of the relative importance to patients of 30 medical innovations. They also provided information about themselves and their practices. Their responses yielded a mean score and a variability score for each innovation. Mean scores were significantly higher for innovations in procedures than in medications and for innovations to treat cardiovascular disease than for those to treat other diseases. The rankings were similar across subgroups of respondents, but the evaluations of a few innovations were significantly related to physicians' age. The great variability in response was usually related to the physician's patient mix.

    Views on progress in quality measurement

    The annual report of the National Committee for Quality Assurance (NCQA) shows progress in all key areas for the second consecutive year. How is information of this kind used to make decisions? An example of how clinical outcome data were viewed within health trusts in Scotland gives some insight into why NHS staff don't set great store by them. Communicating meaningful information is difficult. Why is it, for example, that members of a group targeted by health promotion messages don't respond to the images they see and messages they read?

    The National Committee for Quality Assurance. Fifth annual managed care quality report shows `significant' care/service gains. Reported in Insurance Advocate 2001;112:42–4.

    The National Committee for Quality Assurance (NCQA) released its fifth annual “State of Managed Care Quality Report”. For the second consecutive year health plans made significant gains in all key areas of care and service. The report is based on performance data reported to the NCQA for use in “Quality Compass”, NCQA's database of managed care quality information, and the most comprehensive resource of its kind. The data submitted to the 2001 edition of Quality Compass cover more than 63 million people. To help healthcare organisations quantify the economic impact of these quality improvements, NCQA will soon release an economic model that will allow employers to calculate financial benefits. This year's report includes a preliminary discussion of the model and presents an analysis of the “productivity dividend”.

    Mannion R, Goddard M. Impact of published clinical outcomes data: case study in NHS hospital trusts. BMJ 2001;323:260–3.

    It is yet to be understood how the publication of hospital data in England will impact on staff. This paper may offer some insight. It examines the impact of the publication of clinical outcomes data on NHS trusts in Scotland. Researchers interviewed 48 staff (managers, medical directors, nurses and junior doctors) from eight acute trusts and reviewed background statistics. Indicators had a low profile in the trusts and were rarely cited as informing internal quality improvement or used externally to identify best practice. The indicators were mainly used to support applications for further funding and service development. The poor effect was attributable to a lack of professional belief in the indicators arising from perceived problems around quality of data and time lag between collection and presentation of data; limited dissemination; weak incentives to take action; a predilection for process rather than outcome indicators; and a belief that informal information is often more useful than quantitative data in the assessment of clinical performance. Those responsible for developing clinical indicator programmes should develop robust datasets. They should also encourage a working environment and incentives such that these data are used to improve quality continuously.

    Cox D, Cox AD. Communicating the consequences of early detection: the role of evidence and framing. J Marketing 2001;65:91–103.

    If disease is detected early it can be treated more effectively, saving lives and money. Despite the enormous benefits of early detection, consumers are reluctant to use it. In this paper this is explored from a marketing perspective. Researchers showed a series of messages presented in different ways to 65 women over 50 years of age and asked them: “If you saw this advertisement in a magazine, how likely would you be to go and get a screening breast mammogram?” The overall attitude of the subjects towards screening mammography was assessed by asking them to express their agreement or disagreement with the statement: “I think women my age should have a yearly mammogram”. Respondents think there are short term costs for them in screening which they would rather avoid. If health messages are communicated anecdotally, it tends to reinforce aversion by reassuring people that, in all probability, they will be okay.

    Dwyer CE. Changing behaviors to build better physician/patient relationships. Physician Executive 2001;27:6–10.

    An academic drawing on his own experience of an inpatient admission shares his radical view of a key determinant of healthcare quality. He says: “Descriptively, empirically and demonstrably, the health care system is not about patient health, any more than the governmental system is all about providing citizen service, or the correctional system is all about rehabilitating criminals. All organisations are about power, resources and seekers.” While a patient, he believed it was critical to build positive relationships with the healthcare staff. He spent time taking an interest in staff and became friendly with several people who were caring for him. His human rather than technical relationship with his carers was key to his securing the highest quality of care. He calls on patients to exercise their personal power.

    Organisational perspectives

    The notion that power is an element in any organisation is borne out in a psychological study of health purchaser and provider organisational relationships in the USA. The experience of quality initiatives in informal issues frustrates the formal aims. There is a growing interest in the role of leadership to make progress in implementation.

    Callister RR, Wall JA Jr. Conflict across organizational boundaries: managed care organizations versus health care providers. J Appl Psychol 2001;86:754–64.

    Abstract reproduced from original

    This research examined conflicts that occur across organisational boundaries, specifically between managed care organisations and healthcare providers. Using boundary spanning theory as a framework, the authors identified three factors in the first study (30 interviews) that influence this conflict: (a) organisational power, (b) personal status differences of the individuals handling the conflict, and (c) their previous interactions. These factors affected the individuals' behavioural responses or emotions, specifically anger. After developing hypotheses, the authors tested them in a second study using 109 conflict incidents drawn from nine different managed care organisations. The results revealed that organisational power affects behavioural responses whereas status differences and previous negative interactions affect emotions.

    Becher EC, Chassin MR. Improving the quality of health care: who will lead? Health Aff 2001;20:164–79.

    Abstract reproduced from original

    National interest in the quality of American health care increased dramatically in 1999. The press, the Institute of Medicine, legislators, physicians, and hospitals joined in a vigorous policy discussion. But a similar debate occurred in 1988 following reports from four public agencies that detailed their concerns about healthcare quality. In the intervening decade research has not documented much improvement. The quality problems of US health care are outlined, some of their most prominent causes are reviewed, the biggest obstacles to bringing about major improvement are considered, and the vital role of leadership in achieving this goal is discussed.

    Management and quality of care

    The first empirical study of the causal relationships in the Baldrige model reports its findings. As clinical and organisational worlds come closer together, and in the context of evidence-based medicine, is the time fast approaching when there will be evidence-based management for health care and a pool of knowledge on how to manage healthcare organisations? Several papers offer insights into the management of care. An economist asks of clinical research: if it is not possible or efficient to assess/review every area of care management, what process should determine the areas to be prioritised?

    Meyer SM, Collier DA. An empirical test of the causal relationships in the Baldrige health care pilot criteria. J Operations Manage 2001;19:403–25.

    Abstract reproduced from original

    This research is the first to test empirically the causal relationships in the Malcolm Baldrige National Quality Award (MBNQA) health care pilot criteria. The Baldrige model of quality management for the healthcare industry is tested here using data from 220 US hospitals. Results of confirmatory structural equation modeling show that many of the hypothesized causal relationships in the Baldrige model are statistically significant. This study also clarifies and improves understanding of within-system performance relationships. Baldrige components of Leadership and Information and Analysis are significantly linked with Organizational Performance results while Human Resource Development and Management and Process Management significantly link with Customer Satisfaction. In addition, a comprehensive measurement model grounded in the Baldrige health care criteria for the 28 dimensions of measurement is developed, tested, and found to be valid and reliable. This valid and reliable measurement model allows a fair test of the structural model which tests the relationships among the Baldrige model constructs.

    Walshe K, Rundall TG. Evidence-based management: from theory to practice in health care. Milbank Quarterly 2001;79.

    This papers focuses on the theory and practice of evidence-based management in health care. It poses the question: “Following evidence-based medicine, is there applicability of the ideas of evidence-based practice to healthcare management?” The paper discusses the factors that have contributed to the slow progress in adopting evidence-based management practice and sets out an agenda for its development in health care.

    Hippisley-Cox J, Pringle M, Coupland C, et al. Do single handed practices offer poorer care? Cross sectional survey of processes and outcomes BMJ 2001;323:320–3.

    The paper draws on Trent region data to determine whether there are important differences in performance between group practices and single handed general practitioners and the extent to which any differences are explained by practice characteristics such as deprivation. They were compared on process and outcome measures derived from routinely collected data on hospital admissions and target payments. Multivariate analysis was used to adjust for the confounding effects of general practice characteristics, percentage of Asian residents, percentage of black residents, proportion of men over 75 years, proportion of women over 75 years, rurality, presence of a female general practitioner, and vocational training status. The study provides no evidence that single handed general practitioners are underperforming clinically. The results offer insight into the structural difference between the two types of practice and underline the importance of the effect of other practice characteristics on process and outcome measures.

    Ballard C, Fossey J, Chithramohan R, et al. Quality of care in private sector and NHS facilities for people with dementia: cross sectional survey. BMJ 2001;323:426–7.

    A six hour daytime observation of seven NHS and 10 private sector care facilities for people with dementia found the time distributed in the following ways. People spent 61 minutes (17%) asleep and 108 minutes (30%) either socially withdrawn or not actively engaged in any form of basic or constructive activity. Only 50 minutes (14%) were spent talking (or communicating in other ways) with staff or other residents, and less than 12 minutes (3%) were spent engaged in everyday constructive activities other than watching television (11 minutes (3%)). The remaining 33% of the observation period was spent engaged in basic activities such as eating, going to the toilet, etc. The proposed national standards for care in residential and nursing homes for elderly people describe interaction and daily activity as one of 11 key domains. Improved strategies for joint working between the NHS, social services, and private care providers will ensure that integrated specialist teams can deliver high quality care to these vulnerable patients.

    Guzmán J, Esmail R, Karjalainen K, et al. Multidisciplinary rehabilitation for chronic low back pain: systematic review. BMJ 2001;322:1511–6.

    This systematic review assesses the effect of multidisciplinary biopsychosocial rehabilitation on clinically relevant outcomes in patients with chronic low back pain through a systematic literature review of randomised controlled trials. Ten trials reported on a total of 12 randomised comparisons of multidisciplinary treatment and a control condition. There was strong evidence that intensive multidisciplinary biopsychosocial rehabilitation with functional restoration improves function when compared with inpatient or outpatient non-multidisciplinary treatments.

    Claxton K, Thompson KM. A dynamic programming approach to the efficiency of clinical trials. J Health Econ 2001;20:797–822.

    Abstract reproduced from original

    If the prospective evaluation of all feasible strategies of patient management is not possible or efficient, then a number of questions are posed: (1) Which clinical decision problems will be worth evaluating through prospective clinical research? (2) If a clinical decision problem is worth evaluating, which of the many competing alternatives should be considered “relevant” and be compared in the evaluation? (3) What is the optimal (technically efficient) scale of this prospective research? (4) What is an optimal allocation of trial entrants between the competing alternatives? (5) What is the value of this proposed research? A Bayesian decision theoretical approach to the value of information which can provide answers to each of these questions is presented.

    TOM SMITH

    Research Assistant,

    Judge Institute of Management Studies,

    Cambridge University,

    Cambridge CB1 2AG, UK

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