Understanding informal payments in health care: motivation of health workers in Tanzania

BACKGROUND: There is growing evidence that informal payments for health care are fairly common in many low- and middle-income countries. Informal payments are reported to have a negative consequence on equity and quality of care; it has been suggested, however, that they may contribute to health worker motivation and retention. Given the significance of motivation and retention issues in human resources for health, a better understanding of the relationships between the two phenomena is needed. This study attempts to assess whether and in what ways informal payments occur in Kibaha, Tanzania. Moreover, it aims to assess how informal earnings might help boost health worker motivation and retention. METHODS: Nine focus groups were conducted in three health facilities of different levels in the health system. In total, 64 health workers participated in the focus group discussions (81% female, 19% male) and where possible, focus groups were divided by cadre. All data were processed and analysed by means of the NVivo software package. RESULTS: The use of informal payments in the study area was confirmed by this study. Furthermore, a negative relationship between informal payments and job satisfaction and better motivation is suggested. Participants mentioned that they felt enslaved by patients as a result of being bribed and this resulted in loss of self-esteem. Furthermore, fear of detection was a main demotivating factor. These factors seem to counterbalance the positive effect of financial incentives. Moreover, informal payments were not found to be related to retention of health workers in the public health system. Other factors such as job security seemed to be more relevant for retention. CONCLUSION: This study suggests that the practice of informal payments contributes to the general demotivation of health workers and negatively affects access to health care services and quality of the health system. Policy action is needed that not only provides better financial incentives for individuals but also tackles an environment in which corruption is endemic.

The effect of non-medical factors on variations in the performance of colonoscopy among different health care settings

BACKGROUND: Previous published studies have shown significant variations in colonoscopy performance, even when medical factors are taken into account. This study aimed to examine the role of nonmedical factors (ie, embodied in health care system design) as possible contributors to variations in colonoscopy performance. METHODS: Patient data from a multicenter observational study conducted between 2000 and 2002 in 21 centers in 11 western countries were used. Variability was captured through 2 performance outcomes (diagnostic yield and colonoscopy withdrawal time), jointly studied as dependent variables, using a multilevel 2-equation system. RESULTS: Results showed that open-access systems and high-volume colonoscopy centers were independently associated with a higher likelihood of detecting significant lesions and longer withdrawal durations. Fee for service (FFS) payment was associated with shorter withdrawal durations, and so had an indirect negative impact on the diagnostic yield. Teaching centers exhibited lower detection rates and longer withdrawal times. CONCLUSIONS: Our results suggest that gatekeeping colonoscopy is likely to miss patients with significant lesions and that developing specialized colonoscopy units is important to improve performance. Results also suggest that FFS may result in a lower quality of care in colonoscopy practice and highlight the fact that longer withdrawal times do not necessarily indicate higher quality in teaching centers.

Supplemental Information to the August 2008 Public Health and Health Care Task Force Report, August 2008

The Rebuild Iowa Public Health and Health Care Task Force respectfully submits its report to the Rebuild Iowa Advisory Commission (RIAC) for its consideration of the impacts of the tornadoes, storms, and flooding on Iowans. As the RIAC fulfills its obligations to guide the recovery and reconstruction in Iowa, the impact on the health and well-being of Iowans should be of primary concern. With many areas of the state experiencing devastating damage to their communities, public health and health care are but one of the major challenges. There are critical immediate needs to address the health, safety, and well-being of affected Iowans. This report provides background information on the damages incurred in Iowa from the disasters and additional context for policy and rebuilding discussions. It also offers recommendations to the RIAC for steps that might be taken to address these significant and important challenges.

Quality of care and survival of haemodialysed patients in western Switzerland.

BACKGROUND: Many factors affect survival in haemodialysis (HD) patients. Our aim was to study whether quality of clinical care may affect survival in this population, when adjusted for demographic characteristics and co-morbidities. METHODS: We studied survival in 553 patients treated by chronic HD during March 2001 in 21 dialysis facilities in western Switzerland. Indicators of quality of care were established for anaemia control, calcium and phosphate product, serum albumin, pre-dialysis blood pressure (BP), type of vascular access and dialysis adequacy (spKt/V) and their baseline values were related to 3-year survival. The modified Charlson co-morbidity index (including age) and transplantation status were also considered as a predictor of survival. RESULTS: Three-year survival was obtained for 96% of the patients; 39% (211/541) of these patients had died. The 3-year survival was 50, 62 and 69%, respectively, in patients who had 0-2, 3 and >or=4 fulfilled indicators of quality of care (test for linear trend, P < 0.001). In a Cox multivariate analysis model, the absence of transplantation, a higher modified Charlson's score, decreased fulfilment of indicators of good clinical care and low pre-dialysis systolic BP were independent predictors of death. CONCLUSION: Good clinical care improves survival in HD patients, even after adjustment for availability of transplantation and co-morbidities.

Critical evaluation of outcome scales assessment of lateral ankle ligament reconstruction.

BACKGROUND: Outcome following foot and ankle surgery can be assessed by disease- and region-specific scores. Many scoring systems exist, making comparison among studies difficult. The present study focused on outcome measures for a common foot and ankle abnormality and compared the results obtained by 2 disease-specific and 2 body region-specific scores. METHODS: We reviewed 41 patients who underwent lateral ankle ligament reconstruction. Four outcome scales were administered simultaneously: the Cumberland Ankle Instability Tool (CAIT) and the Chronic Ankle Instability Scale (CAIS), which are disease specific, and the American Orthopedic Foot & Ankle Society (AOFAS) hindfoot scale and the Foot and Ankle Ability Measure (FAAM), which are both body region-specific. The degree of correlation between scores was assessed by Pearson's correlation coefficient. Nonparametric tests, the Kruskal-Wallis and the Mann-Whitney test for pairwise comparison of the scores, were performed. RESULTS: A significant difference (P < .005) was observed between the CAIS and the AOFAS score (P = .0002), between the CAIS and the FAAM 1 (P = .0001), and between the CAIT and the AOFAS score (P = .0003). CONCLUSIONS: This study compared the performances of 4 disease- and body region-specific scoring systems. We demonstrated a correlation between the 4 administered scoring systems and notable differences between the results given by each of them. Disease-specific scores appeared more accurate than body region-specific scores. A strong correlation between the AOFAS score and the other scales was observed. The FAAM seemed a good compromise because it offered the possibility to evaluate the patient according to his or her own functional demand. CLINICAL RELEVANCE: The present study contributes to the development of more critical and accurate outcome assesment methods in foot and ankle surgery.

Interpretation of primary care physicians' attitude regarding rotavirus immunisation using diffusion of innovation theories.

To evaluate primary care physicians' attitude towards implementation of rotavirus (RV) immunisation into the Swiss immunisation schedule, an eight-question internet-based questionnaire was sent to the 3799 subscribers of InfoVac, a nationwide web-based expert network on immunisation issues, which reaches >95% of paediatricians and smaller proportions of other primary care physicians. Five demographic variables were also inquired. Descriptive statistics and multivariate analyses for the main outcome "acceptance of routine RV immunisation" and other variables were performed. Diffusion of innovation theory was used for data assessment. Nine-hundred seventy-seven questionnaires were returned (26%). Fifty percent of participants were paediatricians. Routine RV immunisation was supported by 146 participants (15%; so called early adopters), dismissed by 620 (64%), leaving 211 (21%) undecided. However, when asked whether they would recommend RV vaccination to parents if it were officially recommended by the federal authorities and reimbursed, 467 (48.5%; so called early majority) agreed to recommend RV immunisation. Multivariate analysis revealed that physicians who would immunise their own child (OR: 5.1; 95% CI: 4.1-6.3), hospital-based physicians (OR: 1.6; 95% CI: 1.1-2.3) and physicians from the French (OR: 1.6; 95% CI: 1.2-2.3) and Italian speaking areas of Switzerland (OR: 2.5; 95% CI: 1.1-5.8) were more likely to support RV immunisation. Diffusion of innovation theory predicts a >80% implementation if approximately 50% of a given population support an innovation. Introduction of RV immunisation in Switzerland is likely to be successful, if (i) the federal authorities issue an official recommendation and (ii) costs are covered by basic health care insurance.

Diabetic patients who report receiving processes of diabetic care do not express a better quality of life

Background: Chronic disease management initiatives emphasize patient-centered care, and quality of life (QoL) is increasingly considered a representative outcome in that context. In this study we evaluated the association between receipt of processes of diabetic care and QoL. Methods: This cross-sectional population-based study (2011) used self-reported data from non-institutionalized, adult diabetics, recruited from randomly selected community pharmacies in Vaud. Outcomes included the physical and mental composites of the SF-36 (PCS, MCS) and the disease-specific Audit of Diabetes-Dependent QoL (ADDQoL). Main exposure variables were receipt of six diabetes processes-of care in the past 12 months. We also evaluated whether the association between care received and QoL was congruent with the chronic care model, when assessed by the Patient Assessment of Chronic Illness Care (PACIC). We used linear regressions to examine the association between process measures and the three composites of health-related QoL. Analyses were adjusted for age, gender, socioeconomic status, living companion, BMI, alcohol, smoking, physical activity, co-morbidities and diabetes mellitus (DM) characteristics (type, insulin use, complications, duration). Results: Mean age of the 519 diabetic patients was 64.4 years (SD 11.3), 60% were male and 73% had a living companion; 87% reported type 2 DM, half of respondents required insulin treatment, 48% had at least one DM complication, and 48% had DM over 10 years. Crude overall mean QoL scores were PCS: 43.4 (SD 10.5), MCS: 47.0 (SD 11.2) and ADDQoL: -1.56 (SD 1.6). In bivariate analyses, patients who received the influenza vaccine versus those who did not, had lower ADDQoL and PCS scores; there were no other indicator differences. In adjusted models including all processes, receipt of influenza vaccine was associated with lower ADDQoL (β= - 0.41, p=.01); there were no other associations between process indicators and QoL composites. There was no process association even when these were reported as combined measures of processes of care. PACIC score was associated only with the MCS (β= 1.57, p=.004). Conclusions: Process indicators for diabetes care did not show an association with QoL. This may represent an effect lag time between time of process received and quality of life; or that treatment may be related with inconvenience and patient worry. Further research is needed to explore these unexpected findings.

The Dyadic and Triadic Therapeutic Alliance in Cross-cultural Health Care: The case of Hispanic American Patients

This research project conducted in the Psychology Department of the University of Lausanne (Switzerland) evaluated the therapeutic alliance with Hispanic American Patients. From the patient's perspective, the therapeutic alliance was explored in two types of frameworks: the dyadic and the triadic setting. The dyadic setting is the encounter between a therapist (health professional) and a patient who ideally share the same language. The triadic setting is the encounter of a therapist and a patient who speak different languages, but are able to interact using the help of an interpreter. My specific interest focuses on studying the therapeutic alliance in a cross- cultural setting through a mixed methodology. As part of the quantitative phase, non- parametric tests were used to analyze 55 questionnaires of the Therapeutic Alliance for Migrants - Health Professionals' version (QALM-PS). For the qualitative phase, a thematic analysis was used to analyze 20 transcript interviews. While no differences were found concerning the strength of the therapeutic alliance between the triadic and dyadic settings, results showed that the factors that enrich the therapeutic alliance with migrant patients depend more on an emotional alliance (bond) than on a rational alliance (agreements). Indeed, the positive relationship with the interpreter, and especially with the therapist, relies considerably on human qualities and moral values, bringing the conception of humanity as an important need when meeting foreign patients in health care settings. In addition, the quality of communication, which could be attributed to the type of interpreter in the triadic setting, plays an important role in the establishment of a positive therapeutic relationship. Ce projet de recherche mené au Département de psychologie de l'Université de Lausanne (Suisse) a évalué l'alliance thérapeutique avec les patients hispano-américains. Du point de vue du patient, l'alliance thérapeutique a été étudiée dans deux types de dispositifs: le cadre dyadique et triadique. Le cadre dyadique est la rencontre d'un thérapeute (professionnel de la santé) et d'un patient qui, idéalement, partagent la même langue. Le cadre triadique est la rencontre d'un thérapeute et d'un patient qui parlent différentes langues, mais sont capables d'interagir grâce à l'aide d'un interprète. Mon intérêt porte en particulier sur l'étude de l'alliance thérapeutique dans un cadre interculturel au travers d'une méthodologie mixte. Dans la phase quantitative, des tests non paramétriques ont été utilisés pour les analyses des 55 questionnaires de l'alliance thérapeutique pour les migrants, version - professionnels de la santé (QALM-PS). Pour la phase qualitative, une analyse thématique a été utilisée pour l'analyse des 20 entretiens transcrits. Bien qu'aucune différence n'a été constatée en ce qui concerne la force de l'alliance thérapeutique entre les cadres dyadiques et triadiques, les résultats montrent que les facteurs qui enrichissent l'alliance thérapeutique avec les patients migrants dépendent plus de l'alliance émotionnelle (lien) que sur une alliance rationnelle (accords). En effet, la relation positive avec l'interprète, et en particulier avec le thérapeute, repose en grande partie sur des qualités humaines et des valeurs morales, ce qui porte la conception de l'humanité comme un besoin important lors de la rencontre des patients étrangers dans un cadre de santé. En outre, la qualité de la communication, qui pourrait être attribuée au type d'interprète dans le cadre triadique, joue un rôle important dans l'établissement d'une relation thérapeutique positive.

La médecine ambulatoire youth-friendly. [Youth-friendly outpatient care].

Ambulatory pediatric and family medicine takes care of adolescent patients, most of whom regularly consult a physician. Consultations with young people involve issues specifically related to their age. Regarding health care systems and physicians, adolescents' expectations vary from those of adults, not so much in terms of the issues discussed but in terms of the priorities that they give to them. Confidential interviews are not always proposed but are highly appreciated, as are certain personal qualities on the part of the caregivers such as honesty, respect, and friendliness. Finally, easy access to care together with the continuity of care are essential. Prevention of risk behaviors by screening and health education is clearly insufficient. This issue could be approached during the consultation through a psychosocial history. This is a good opportunity to discuss sensitive issues that adolescents seldom bring up themselves. More systematic prevention would probably decrease youth morbidity and mortality, which are both closely related to risk behaviors. To meet these expectations and special health care needs, the World Health Organization has developed the concept of youth-friendly health services. This concept can be applied in both a specialized adolescence center and a pediatric or family practice. Youth-friendly services are still rarely evaluated but seem to bring a clear benefit in terms of patient satisfaction and access to care.

Treatment patterns and health care resource utilization in a 1-year observational cohort study of outpatients with schizophrenia at risk of nonadherence treated with long-acting injectable antipsychotics

Purpose: To describe (1) the clinical profiles and the patterns of use of long-acting injectable (LAI) antipsychotics in patients with schizophrenia at risk of nonadherence with oral antipsychotics, and in those who started treatment with LAI antipsychotics, (2) health care resource utilization and associated costs. Patients and methods: A total of 597 outpatients with schizophrenia at risk of nonadherence, according to the psychiatrist's clinical judgment, were recruited at 59 centers in a noninterventional prospective observational study of 1-year follow-up when their treatment was modified. In a post hoc analysis, the profiles of patients starting LAI or continuing with oral antipsychotics were described, and descriptive analyses of treatments, health resource utilization, and direct costs were performed in those who started an LAI antipsychotic. Results: Therapy modifications involved the antipsychotic medications in 84.8% of patients, mostly because of insufficient efficacy of prior regimen. Ninety-two (15.4%) patients started an LAI antipsychotic at recruitment. Of these, only 13 (14.1%) were prescribed with first-generation antipsychotics. During 1 year, 16.3% of patients who started and 14.9% of patients who did not start an LAI antipsychotic at recruitment relapsed, contrasting with the 20.9% who had been hospitalized only within the prior 6 months. After 1 year, 74.3% of patients who started an LAI antipsychotic continued concomitant treatment with oral antipsychotics. The mean (median) total direct health care cost per patient per month during the study year among the patients starting any LAI antipsychotic at baseline was 1,407 ( 897.7). Medication costs (including oral and LAI antipsychotics and concomitant medication) represented almost 44%, whereas nonmedication costs accounted for more than 55% of the mean total direct health care costs. Conclusion: LAI antipsychotics were infrequently prescribed in spite of a psychiatrist-perceived risk of nonadherence to oral antipsychotics. Mean medication costs were lower than nonmedication costs.

Impact of medical practice guidelines on the assessment of patients with acute coronary syndrome without persistent ST segment elevation.

OBJECTIVE: To assess the impact of introducing clinical practice guidelines on acute coronary syndrome without persistent ST segment elevation (ACS) on patient initial assessment. DESIGN: Prospective before-after evaluation over a 3-month period. SETTING: The emergency ward of a tertiary teaching hospital. PATIENTS: All consecutive patients with ACS evaluated in the emergency ward over the two 3-month periods. INTERVENTION: Implementation of the practice guidelines, and the addition of a cardiology consultant to the emergency team. MAIN OUTCOME MEASURES: Diagnosis, electrocardiogram interpretation, and risk stratification after the initial evaluation. RESULTS: The clinical characteristics of the 328 and 364 patients evaluated in the emergency ward for suspicion of ACS before and after guideline implementation were similar. Significantly more patients were classified as suffering from atypical chest pain (39.6% versus 47.0%; P = 0.006) after guideline implementation. Guidelines availability was associated with significantly more formal diagnoses (79.9% versus 92.9%; P < 0.0001) and risk stratification (53.7% versus 65.4%, P < 0.0001) at the end of initial assessment. CONCLUSION: Guidelines implementation, along with availability of a cardiology consultant in the emergency room had a positive impact on initial assessment of patients evaluated for suspicion of ACS. It led to increased confidence in diagnosis and stratification by risk, which are the first steps in initiating effective treatment for this common condition.

Evaluer les troubles de la marche des personnes âgées au cabinet [Assessment of gait disorders in older people]

Gait disorders are frequent and important to assess in older people because they provide unique diagnostic and prognostic information. Gait disorders can be regarded as a marker of frailty because they are associated with several adverse consequences, including falls, cognitive disorders, functional decline, institutionalization, hospitalization, and death. Using structured instruments, gait assessment could be performed in primary care practice to classify the level of sensorimotor deficit and provide the necessary information to decide how to best intervene to improve gait performances, prevent falls as well as functional decline.