International
Call for Papers
Learning from International Policy Change
Chair: Huw Davies, Ph.D., M.A., M.Sc.
Sunday, June 6 • 11:30 a.m.-1:00 p.m.
• Managing the Workforce for a Changing Healthcare
System: Lessons from the European Experiences
Carl-Ardy Dubois, M.D., M.Sc., Ph.D., Martin McKee, M.D.,
Ph.D.
Presented by: Carl-Ardy Dubois, M.D., M.Sc., Ph.D., Fellow,
European Observatory on Health Care Systems, London
School of Hygiene and Tropical Medicine, Keppel Street,
London, WC1E 7HT; Tel: 44 207 612 7811; Fax: 44
207.612.7812; E-mail: Carl-Ardy.Dubois@lshtm.ac.uk
Research Objective: This paper forms part of a major study
by the European Observatory on Health Care Systems that
aims to establish to which extent current policies and
practices related to the management of the healthcare
workforce are aligned with the challenges facing healthcare
systems. Two closely related objectives are firstly to document
how healthcare systems in Europe are dealing with emerging
workforce issues and secondly to identify what supportive
strategies may be promoted to optimise the management of
the workforce in the changing healthcare environment.
Study Design: The approach used in this study is
comparative. At one level, a series of common workforce
issues are examined, drawing on an extensive range of
information sources. At a second level, a set of comparative
case studies are used to provide detailed accounts of how 10
selected European countries are dealing with issues related to
key aspects of the workforce management: staffing and
planning, education and training, performance management,
labour relations, and regulation.
Population Studied: The study covers European countries
with a specific focus on the European Economic Area, the
transition countries of Central and Eastern Europe (CEE), and
Russia. Countries selected for the case studies include: United
Kingdom, Germany, France, Norway, Spain, Netherlands,
Poland, Lithuania, Malta, and Russia.
Principal Findings: Across Europe, the processes of
transition of health and health care are leading to fundamental
alterations in the profile of healthcare workers, their
workplaces, the content and the outcomes of their work.
Explicit workforce policies are being increasingly incorporated
into health policies and failure to do so, particularly in some
transition countries of CEE, has hampered the capacity to
achieve the health sector reforms. Wide-ranging initiatives are
being developed by national governments with potential to
bring significant changes in how the healthcare workforce is
governed and managed. Recurrent failures of a traditionally
fragmented and physician-oriented model of workforce
planning have prompted, in many jurisdictions, a move
towards more integrated approaches to planning. The
processes of re-regulation of healthcare providers suggest a
paradigmatic shift from professional self-regulation and
macro-managerial controls towards a greater emphasis on
public accountability and micro regulation. New patterns of
flexibility go beyond the traditional focus on shift working and
also draw increasingly upon innovative models of division of
labour, changes in scope of practice, and redesign of the
incentives. It appears that common pressures faced by
different countries and institutional demands arising from the
European integration are creating a commonality of patterns
in many areas notably as regards education, training and
recognition of professional qualifications. However, despite
many similar features, the models of management of health
workers in Europe show marked variability. In particular
different approaches to labour relations reflect regulatory
styles inherited from different institutional contexts.
Conclusions: Effective workforce policies emerge as a critical
component of health policy and a sine qua non for effective
reform of the health sector. Countries may inform each other
on appropriate and innovative strategies to cope with the
challenging healthcare workforce issues. However, given the
pervasive influence of institutional structures in each country,
innovations that are primarily technical and relatively
institution-free are likely to be more quickly transferred.
Implications for Policy, Delivery or Practice: This study
offers options to policy makers to improve healthcare
outcomes through changes in the governance of health
system personnel. Building a new healthcare workforce will
require a comprehensive agenda, fundamental alterations in
some existing models and experimentation of more creative
options.
Primary Funding Source: Budget of the European
Observatory on Health Care Systems (Consortium of funders)
and Canadian Health Services Research Foundation (CHSRF)
• Organizational Turnaround: Lessons from a Study of
'Failing' Health Care Providers in England
Naomi Fulop, B.Sc., M.P.H., Ph.D., Fiona Scheibl, B.A., Ph.D.,
Nigel Edwards, B.A., M.B.A., Gerasimos Protopsaltis, B.A.,
M.A.
Presented by: Naomi Fulop, B.Sc., M.P.H., Ph.D., Senior
Lecturer, Public Health and Policy, London School of Hygiene
and Tropical Medicine, Keppel Street, London, WC1E 7HT;
Tel: +44 20 7927 2458; Fax: +44 20 7612 7843; E-mail:
naomi.fulop@lshtm.ac.uk
Research Objective: There is a large literature on
management turnaround in the corporate sector, most of
which focuses on strategies for dealing with survivalthreatening performance decline. However, in health care
such literature is rare. With the public reporting of
performance data such as the 'star ratings' system in the
English NHS (a composite measure used to rank health care
organisations), the question of how to address 'failing' health
care organisations has come to the fore. Our objective was to
study the markers for 'failure' and the approaches to
management turnaround in health care organisations. In
particular, the policy of 'franchising' in the English National
Health Service (NHS), whereby the chief executive of a failing
organisation is replaced, is examined
Study Design: The study has two elements: in the first phase,
five case studies were conducted with hospitals perceived as
'failing', prior to the introduction of the star rating system,
where the management had been replaced. In the second
phase, four of these five cases were followed up and a further
four case studies added that had scored the lowest (zero
stars) in the performance assessment system and had their
management team replaced. These four cases were subject to
intervention by teams from the Modernisation Agency, an
agency of the English Department of Health charged with
acting as 'a catalyst for change' to reform the NHS. Data were
collected to examine the markers and responses to failure,
strategies for turnaround, and the impact of these strategies.
Data include semi-structured interviews with 99 key
stakeholders both internal and external to the hospitals,
analysis of local media coverage, and changes in 'star ratings'
assessmen
Population Studied: Nine acute hospitals in England
perceived as 'failing' and where the top management team
were replaced.
Principal Findings: Common markers for failure included lack
of clear management structures and processes; and a lack of
engagement of clinicians in the management process. Initial
external responses to failure were slow and limited to changes
to the top management team. Subsequent responses included
intervention by Modernisation Agency teams. Turnaround
strategies included internal reorganisations to engage
clinicians in management and introduce new management
systems; attempts to change organisational culture; and a
focus on relations with external stakeholders. Changes in the
'star ratings' assessment indicated that, in some cases,
performance appeared to decline before it improve
Conclusions: This study provides important new data on the
markers for organisational failure in health care, on the impact
of various responses, and the time taken to turn round failing
health care organisations.
Implications for Policy, Delivery or Practice: Reasons for
organisational 'failure' in health care and how to respond have
not been well understood. Responses require careful
diagnosis and prescription, but it seems important not to
delay too long before taking action. Changing the chief
executive appears to be a necessary but not sufficient
response. Organisational turnaround in complex health care
organisations takes time, possibly longer than in nonprofessionally dominated organisations, and its sustainability
in the long-term is questionable.
Primary Funding Source: NHS Confederation
• Market Reforms in Europe: Dynamics of Policy Fashion
Michael Harrison, Ph.D.
Presented by: Michael Harrison, Ph.D., Senior Research
Scientist, CDOM, Agency For Healthcare Research and
Quality, 540 Gaither Road, Rockville, MD 20850; Tel:
301.427.1434; E-mail: mharriso@ahrq.gov
Research Objective: This paper presents a model of forces
which lead to the fashion-like waxing and waning of health
system reform policies. The model extends past studies of
policy agenda setting and research on fashion in other areas,
such as management. The model is used to account for the
rapid rise and decline of support among European policy
makers for using market forces to reform publicly-regulated
health systems.
Study Design: The model derives from qualitative analysis of
104 in-depth, semi-structured interviews conducted during the
mid-1990s in the United Kingdom, Sweden, and the
Netherlands. Respondents reported on the reforms’
development and impacts in their own organization and in
other domains familiar to them. Site visits, consultations with
local experts, published and unpublished documents and
research reports provided additional data.
Population Studied: Managers in public purchasing
authorities and hospitals, politicians, physicians, nurses,
researchers, and consultants.
Principal Findings: After their initial enthusiasm and interest
in the late 1980s and early 1990s, politicians in the countries
studied quickly enacted ambitious quasi-market reforms, then
grew less supportive of them, and began searching for other
policy options. Proposals and policies for market-oriented
reform moved through a cycle, involving (1) fashion setting,
(2) policy formation and adoption, (3) implementation, and
(4) feedback from implementation. During fashion setting
proponents of reform drew inspiration from an international
movement advocating deregulation and privatization of public
services. Foreign – and particularly American -- fashion
setters led the way. During policy formation and adoption,
policy actors in each country developed local versions of
managed competition, diffused program proposals, and
forged supporting coalitions. Their policy discourse was
largely enthusiastic and uncritical, and they paid little attention
to dissenting voices. During policy implementation
unforeseen difficulties and costs surfaced; actors who were
uninvolved in earlier stages became vocal; discourse about
reform became more reasoned and critical. Conflicts emerged
among reform priorities and between the reforms and other
widely-held values. Worst of all, the reforms did not quickly
deliver the hoped-for-benefits. Disillusion set in, public and
political support for the original programs dwindled, and the
stage was set for further waves of policy fashion.
Conclusions: Policy fashion appears to be unavoidable and
does bring benefits, including experimentation and
challenging taken-for-granted ideas. However, fashion leads
policy makers and users to neglect analysis of the feasibility
and implications of new policies. Nor does the fashion cycle
provide much opportunity for learning and improvement of
programs during implementation. Thus rapid adoption and
abandonment of programs wastes resources, often leads to
failure to achieve worthwhile policy objectives, burdens those
responsible for implementation, and leaves them cynical
about the prospects for meaningful system improvement.
Implications for Policy, Delivery or Practice: Policy makers
can take several steps to reduce these negative effects of the
fashion cycle: Assure that people responsible for
implementation also participate in policy formulation and
planning; experiment with policy options before full-scale
implementation; sponsor research and rapid feedback on the
implementation of new policies; train and encourage people at
all levels to engage in diagnostic and critical thinking about
policies and their implementation
• How Does the Quality of Medical Care Compare in Five
Countries?
Peter Hussey, B.A., Gerard Anderson, Ph.D., Robin Osborn,
Vivienne McLaughlin, John Millar, M.D., Arnold Epstein, M.D.
Presented by: Peter Hussey, B.A., Ph.D. Candidate, Health
Policy and Management, Johns Hopkins School of Public
Health, 624 N. Broadway, HH305, Baltimore, MD 21205; Tel:
410.955.7314; Fax: 410.955.2301; E-mail: pete@jhu.edu
Research Objective: This study aimed to compare indicators
of the quality of medical care across five countries. Despite
significant interest in measuring and reporting quality of
medical care in most industrialized countries, to date there
have been little internationally comparable data available.
International quality of medical care data will allow countries
to compare their performance to other countries’, offering an
alternative standard to expert recommendations.
Study Design: The Commonwealth Fund International
Working Group on Quality Indicators collected data on 22
indicators of medical care quality for Australia, Canada,
England, New Zealand, and the United States. The indicators
were selected by a panel of researchers and government
officials using the following criteria: feasibility, scientific
soundness, interpretability, actionability, and importance. The
measures include 5-year cancer relative survival rates, 30-day
case-fatality rates after acute myocardial infarction and stroke,
the breast cancer screening rate, and the asthma mortality
rate.
Population Studied: The quality indicators were compared at
the national level in Australia, Canada, New Zealand, the
United Kingdom, and the United States.
Principal Findings: The results show that none of the five
countries consistently scores the best or worst on all of the
indicators. In addition, each country has either the best or the
worst score on at least one indicator. In other words, no
country scores consistently the best or worst overall, and each
country has at least one area of care where it could potentially
learn from international experience. Each country also has an
area where it could potentially teach others. While the United
States often performs relatively well for this set of indicators, it
is difficult to conclude that the U.S. is getting good value for
its medical care dollar from these data.
Conclusions: Previous U.S. research has shown that
Americans receive, on average, 55% of the “gold standard” of
experts’ recommended medical care. International
comparisons provide a complementary, more realistic, set of
benchmarks in addition to the “gold standard.” The
comparisons on this set of quality indicators show that each
country performs well in some areas and poorly in others
compared to other countries. None of the countries
approaches the “gold standard.” More work is clearly needed
to expand the scope and depth of the indicator set in order to
use it to judge overall health system performance, and further
investment in data collection and international harmonization
of indicators to allow valid international comparisons is
necessary.
Implications for Policy, Delivery or Practice: The results are
intended to draw attention to potential opportunities to
improve medical care in the five countries, raise questions
about why some countries do well on some measures and
others do poorly, provoke debate within countries about
health care priorities and policies, and stimulate efforts to
examine, refine, improve, and expand the data.
Primary Funding Source: CWF
• A Decade of Evidence-Based Prescription Drug
Purchasing in British Columbia
Steve Morgan, Ph.D., Ken Bassett, M.D. Ph.D., Barbara
Mintzes, Ph.D.
Presented by: Steve Morgan, Ph.D., Assistant Professor,
Centre for Health Services and Policy Research, University of
British Columbia, 429 - 2194 Health Sciences Mall, Vancouver,
British Columbia V6T 1Z3; Tel: 604.822.7012; Fax:
604.822.5690; E-mail: morgan@chspr.ubc.ca
Research Objective: 2004 marks the tenth anniversary of the
Therapeutics Initiative (TI) at the University of British
Columbia. The TI is an academic group that provides the
provincial “PharmaCare” plan with the ongoing evidentiary
support needed to implement and maintain restrictions on
public subsidies until manufactures provide scientifically valid
evidence of a comparative final health outcomes advantage.
Such “outcomes-based drug coverage policies” are
becomingly increasingly necessary with rapidly growing
investment in the pharmaceutical component of modern
health care systems. The aim of this project is to outline the
program of outcomes-based drug coverage supported by the
expert advice provided by the TI.
Study Design: Telephone and in-person interviews were
conducted with individuals that held senior decision-making
positions in the BC PharmaCare program during the past
decade. Based on these interviews and input from member of
the TI, we constructed three case studies pertaining to drug
coverage policies that were influenced by the evidence
assessed, synthesized, and communicated by the
Therapeutics Initiative. We describe the evolution of the
decision-making framework, the role of the Therapeutics
Initiative, and the impact on provincial drug costs and quality
of care.
Population Studied: Senior managers in the British Columbia
Ministry of Health and academics at the University of British
Columbia.
Principal Findings: Decision makers in British Columbia have
been rationing drug coverage based on scientific evidence of
comparative health benefit for ten years. Evaluations of the
policies described in our case studies indicate that they save
PharmaCare at least $35 million annually (14 percent of
program costs) without inducing adverse effects often
associated with indiscriminate cost shifting. What
distinguishes PharmaCare’s policies from those of other drug
benefit providers is the consistent applications of high
standards of evidence to funding decisions.
Conclusions: Outcomes-based drug coverage helps to control
expenditures while avoiding the financial inequities and
adverse health impacts often associated with indiscriminate
cost shifting. The outcomes-based decision-making
framework places a burden of proof on manufacturers and
creates a need for an objective review of the scientific
evidence. Implementing and then maintaining outcomesbased policies therefore requires dedicated academic partners
who support the decision-making process through ongoing
communication and the regular provision of timely and
defensible assessments.
Implications for Policy, Delivery or Practice: The broad and
rigorous application of the framework for outcomes-based
drug coverage like that applied by BC PharmaCare could
generate significant pharmaceutical savings without causing
side effects associated with indiscriminate cost sharing
policies. Substantive partnerships between committed
decision makers and objective experts are vital to such policy
success. Because of the inherent interdependence, the
relationship between decision makers and academic advisors
must be scrutinized and managed to ensure objectivity of an
outcomes-based decision-making process.
Primary Funding Source: CWF
Related Posters
Poster Session B
Tuesday, June 8 • 7:30 a.m.-8:45 a.m.
• Applying CAHPS Instruments in the Dutch Healthcare
System to Track Consumer Experience and Improve
Performance
Onyebuchi Arah, M.D., D.Sc., Aldien Poll, M.Sc., Piet Stam,
M.Sc., Han de Vries, M.Sc., Diana Delnoij, Ph.D., Niek
Klazinga, M.D., Ph.D.
Presented by: Onyebuchi Arah, M.D., D.Sc., NIHES Fellow,
Social Medicine, Academic Medical Center of the University of
Amsterdam, Meibergdreef 9, P.O. Box 22700, Amsterdam,
1100 DE; Tel: 0031.6.2857.1158; Fax: 0031.20.697.2316; E-mail:
o.a.arah@amc.uva.nl
Research Objective: To assess the potential applicability of
translated Consumer Assessment of Health Plans Study
(CAHPS) instruments for providing valid and meaningful
healthcare consumer experience data within the context of the
Dutch healthcare system
Study Design: After extensive review of existing international
and national consumer experience survey instruments, the
United States CAHPS was selected for brevity, clarity and
potential for use within the Dutch healthcare policy context.
We examined the conceptual, item, and semantic equivalence
of CAHPS in the Netherlands. Two instruments, ‘health plan’
and ‘hospital’ CAHPS, were translated into Dutch (a 67-item
alg-NL-CAHPS and a 70-item NL-HCAHPS) and piloted. A
third instrument (a 118-item DM-NL-QUOTE), aimed at
diabetic patients, was also developed using CAHPS®
principles, and was based on the Dutch validated QUOTE
instrument. All three instruments were administered by mail,
with two reminders, in accordance with the Dillman and the
CAHPS Users’ Network recommendations. The surveys were
conducted from October to December 2003.
Population Studied: We surveyed three adult groups (1000
insured, 2 times 1000 hospital discharged patients, and 1000
insured who have diabetes mellitus) randomly sampled from
the insured population of Agis, a major regional health insurer
that covers some half a million people.
Principal Findings: Initial evaluation suggests that the US
CAHPS constructs are not alien to the Dutch situation. The
response rates to the ‘health plan,’ ‘hospital,’ and ‘diabetes’
modules are 56%, 65%, and 72% respectively. The results of
the psychometric and performance analyses are expected in
March 2004. There has also been increased stakeholder and
political interest during the pilot testing of the draft surveys.
Conclusions: In the Dutch healthcare context, consumer
experience data are playing an increasing role in the
evaluation, decision making and contracting of the various
stakeholders. First experience suggests that the CAHPS
approach may be useful for the two purposes explored in this
study: performance of the insurer (accountability) and
performance of the providers of hospital and diabetes care
(contracting). Cross-national learning involving the United
States and the Netherlands has so far proven fruitful.
Implications for Policy, Delivery or Practice: Consumer
experiences with care are an important data source for
evaluating the functioning of the healthcare system. Like in the
USA, in the Netherlands, consumer experience data are used
for various purposes. Recent policy reforms stimulate the use
of consumer experience data: (a) to assess the functioning of
health insurers in their role as contractors with providers; and
(b) to provide consumers and insurers data on which to base
their choice and contracting. Capturing the user’s perspective,
as anticipated in this study, augments the technical
performance indicators being developed in the Dutch
healthcare system.
However, the present configuration of the Dutch healthcare
system limits consumer choice where insurers still contract
with most providers. We assume that this will change given
the planned reforms that envision an increased liberalization
of the healthcare market by 2006. This study contributes to
the necessary Dutch healthcare system renewal aimed at
increasing transparency of the performance of insurers and
providers.
Primary Funding Source: Agis Health Insurance Company
(who has no influence on research, data or publication)
• Public Health Policy and Infant Nutrition Practices: A
Comparative Study of International Environments for
Breastfeeding
Dana Lee Baker, Ph.D., Amber Ann Wagner, M.P.A. Candidate
Presented by: Dana Lee Baker, Ph.D., Assistant Professor,
Harry S Truman of Public Affairs, University of MissouriColumbia, 118 Middlebush Hall, Columbia, MO 65203; Tel:
573.882.0363; Fax: 573.884.4872; E-mail:
bakerdan@missouri.edu
Research Objective: In this paper, we conduct an
international study of the relationships between breastfeeding
practices, the public health and public policy infrastructures,
and child health indicators. Our central research questions
are: 1) What factors increase the likelihood that a nation will
adopt strong pro-breastfeeding legislation?; 2) What factors
influence aggregate breastfeeding practice?
Study Design: To gain insight into these questions, we use
regression analysis testing variables such as median
breastfeeding duration, median age of introduction of
complementary foods, female workforce participation,
economic indicators, breastfeeding legislation, public health
investment, parental leave policies and an index of
government support of breastfeeding beyond legislation.
Population Studied: General population
Principal Findings: We have found intriguing correlations
(and bases for international comparison) between national
characteristics and the breastfeeding policies and practices of
nations.
Conclusions: Recent medical research has demonstrated
tangible benefits including increased intelligence, improved
immunities to childhood diseases and a decrease in the
tendency to develop diseases later in life such as asthma and
diabetes. Breastfeeding dramatically declined worldwide in the
1950s and 1960s. Significant work has been done recently in
some nations in an attempt to change attitudes and practices.
However, socio-cultural context and policy infrastructure
remain influential today.
Implications for Policy, Delivery or Practice: Breastfeeding
is believed to be fundamental to better infant health and
development. The results of this study help to demonstrate
which policy levers and socio-economic characteristics tend to
be most conducive to breastfeeding internationally.
• Health Without Wealth Revisited
Thomas Croghan, M.D., Aviva Ron, Sc.D., Amanda Beatty,
MPAID, Ross Anthony, Ph.D.
Presented by: Amanda Beatty, MPAID
Research Objective: To assess determinants of health
improvements in developing countries.
Study Design: This qualitative policy analysis was divided into
two phases. In the first, we conducted a literature review and
analysis of secondary data to determine developing countries
that had achieved “breakthrough” improvements in health
status in spite of the constraints of low-economic status and
low levels of health-related spending. In the second, we
conducted pair-wise comparisons of three countries that had
achieved breakthrough improvements in child mortality with
three countries that had not.
Population Studied:
Principal Findings: Breakthrough improvements in health
appear unrelated to country-level income, nutritional and
educational attainment, health-related spending, poverty
levels, economic growth, and economic and gender inequality,
at least within the income band studied here.
Conclusions: The path to improved health status in
developing countries is not straightforward, and there is still
much to learn. It appears that the breakthrough
improvements in health observed in some countries can be
achieved in spite of economic constraints, already significant
attainment in education and nutrition status, and social and
cultural barriers that may limit rapid changes in poverty and
inequality.
Implications for Policy, Delivery or Practice: The lack of
progress in many nations, and the slowing progressing in
others, toward reaching health-related Millennium
Development Goals, including under-5 mortality, calls for an
in-depth understanding of how improvement was achieved in
the countries studied.
Primary Funding Source: RAND Corporation, Private
Donation
• Regulatory Policy and the Supply of Ambulatory Services
Martin Dlouhy, Ph.D.
Presented by: Martin Dlouhy, Ph.D., Visiting Scholar, School
of Public Health, University of California Berkeley, 140 Warren
Hall, MC 7360, Berkeley, CA 97420; Tel: 510.643.1910; Fax: ; Email: dlouhy@uclink.berkeley.edu
Research Objective: To evaluate the impact of regulation on
the supply of ambulatory services and their geographical
distribution in the Czech Republic during the health reforms
1990-2002.
Study Design: The analysis of regulatory policy is based on
the review of literature, the analysis of national legislation, and
the quantitative analysis of trends in the supply and regional
distribution of services. Four measures of inequality were
used: the Gini coefficient, Robin Hood Index, the absolute and
relative ranges.
Population Studied: Ambulatory health providers in the
Czech Republic 1990-2002. All data comes from the Institute
of Health Information and Statistics of the Czech Republic.
Principal Findings: Despite recommendations that excesive
capacity should be reduced, after 12 years of reforms, there
was 28.2% increase in the number of ambulatory physicians
per capita and the number of contacts increased by 10.7%.
The inequality measures do not show improvements in the
regional distribution of services. For example, a quarter of
ambulatory services in psychiatry is located in the capital.
Conclusions: The deregulation introduced in 1992 can be
seen as a failure. It caused an excessive expansion of services.
The budgetary regulation introduced in 1997 led to a financial
stability of health insurance system, but it did not have a great
impact on the number and distribution of ambulatory
physicians. The supply of ambulatory service is high, especially
in the capital. Inequalities in the regional distribution were not
removed by the regulation.
Implications for Policy, Delivery or Practice: The
combination of fee-for-service system, free contracting and
privatization during 1992-1997 brought many problems,
however, the budgeting during 1997-2002 just hid the
problems by seeming financial balance in the sector and
postponed their real solutions. The appropriate design of
incentives, the active purchasing and contracting policies are
needed. The fundamental system issues as managed care,
quality assurance and other has to be also addressed by the
regulation.
Primary Funding Source: Fogarty International
• An Examination of U.K. and U.S. Long Term Care
Policies and the Effects on Family Expectations for
Residential Care Practices
Debra Dobbs, Ph.D.
Presented by: Debra Dobbs, Ph.D., NRSA Post Doctoral
Fellow, Sheps Center for Health Services Research, University
of North Carolina Chapel Hill, 101 Conner Drive, Suite 302,
Chapel Hill, NC 27599; Tel: 919.843.3084; Fax: 919.966.1634;
E-mail: debra_dobbs@unc.edu
Research Objective: The purpose of this qualitative study was
to examine how cross national differences in the roles and
responsibilities of the state (public) and the market (private
organizations) with regard to provision of long term care, lead
to differences in residential care practices and ultimately
differences in family expectations for care.
Study Design: Indepth structured interviews with family
members about their expectations for care for their relatives
residing in residential care settings and how these
expectations were or were not met. Interview data was coded
for similarities as well as differences in expectations between
the U.K. and U.S. sample populations.
Population Studied: A sample of 24 family members from
five residential care homes (RCs) in Exeter in England and 25
family members from six RCs in Kansas in the U.S. were
interviewed.
Principal Findings: Similarities between the two samples
included 1) the importance of choosing a setting that was
homelike; and 2) having staff that delivered resident-centered
care. In the U.K.,residents were not provided the option of
private rooms or private toilets, which was problematic to
family members. The differences in expectations were related
to the differences in: 1) financing of residential care and aging
in place; 2) the level of regulation of RC and state agency
involvement and coordination of care; and 3) the degree of a
medical model of care and staff qualifications.
Conclusions: Similarities suggest that both nursing homes
and residential care settings should create a homelike
environment, including such things as private rooms and
bathrooms, spaces for visiting, allowing own furniture, and
flexible schedules for meals and baths. LTC facilities also
need to focus on resident centered care to meet the growing
consumer demand for this type of care. Aging in place is
desired by both the U.K. and the U.S. sample of family
members, but not as achievable in the U.S., because of the
private pay system in place as compared to the largely publicly
funded system in the U.K. Primary Care Teams play an
important role in reducing staff workload in the U.K. sample,
which may result in lower levels of staff turnover, as compared
to U.S. sample. High turnover is expected and observed in
the U.S. sample which is in sharp contrast to the U.K. sample,
reasons for this are numerous - medical models of care, low
status, minimal rewards and low prestige for direct care staff,
no chances to advance in their jobs.
Implications for Policy, Delivery or Practice: Clearly, both
systems have their advantages and disadvantages. It would
be ideal to borrow the best of both of the residential care
systems to improve upon each. In both systems, nursing
home providers need to do a better job of creating socially
desireable environments and can learn from social models of
care developed by the Assisted Living/Residential Care
industry. Affordable residential care alternatives and
mechanisms will need to be put into place in order for aging
in place to be possible in the U.S. Health care career ladders
and higher salaries for direct care staff in the U.S. may reduce
turnover in this population.
Primary Funding Source: AHRQ-NRSA funding
• Coronary Artery Bypass Graft Surgery (CABG) Mortality
and Length of Stay (LOS) in the United Kingdom
Compared with the United States
David Foster, Ph.D., M.P.H., Sivana Heller, M.D., M.P.H.,
Janet Young, M.D., MHSA, Phillip James
Presented by: David Foster, Ph.D., M.P.H., Vice President,
Clinical Informatics, Clinical Informatics, Solucient, LLC, 5400
Data Court, Suite 100, Ann Arbor, MI 48108; Tel:
734.669.7982; Fax: 734.930.7611; E-mail:
dfoster@solucient.com
Research Objective: To compare inpatient mortality and
length of stay in coronary artery bypass graft patients in the
United Kingdom with those of similar patients in the United
States
Study Design: Retrospective cohort using observational data.
The diagnosis coding system used in the US is ICD-9-CM; the
corresponding system in the UK is ICD-10. Therefore, we
used a diagnosis grouping system from the US Agency for
Healthcare Research and Quality (AHRQ) that is applicable to
both ICD-9-CM and ICD-10. This Clinical Classification
Software (CCS) grouping methodology was used to create 10
diagnostic categories which covered more than 99% of both
the US and UK CABG discharges. These diagnostic categories
provided a mechanism for case-mix adjustment. Patient age,
sex, number of diagnosis codes, and emergency versus
routine admission were also used to adjust for potential
confounding.
Population Studied: Inpatients in the United Kingdom and in
the United States who received a coronary artery bypass graft
surgery in the second calendar quarter of 2002 through the
first calendar quarter of 2003. There were 97,326 cases from
the US, and 16,395 from the UK included in this study.
Principal Findings: Unadjusted comparisons showed higher
LOS and mortality rates for patients who received a CABG in
the UK than for similar patients treated in the US. Adjusted
CABG mortality and LOS are both significantly higher in the
United Kingdom compared with patients in the United States.
Patients who were admitted on an emergency basis were
significantly more likely to die than routinely admitted
patients, and female and older patients were significantly
more likely to die during their stay than male and younger
patients, respectively, regardless of country where treatment
took place.
Conclusions: Adjusted length of stay, and in-hospital
mortality rates are significantly higher for similar patients
undergoing CABG surgery in the UK versus the US during the
time period under study.
Implications for Policy, Delivery or Practice: Further
international studies are needed to help explain why
differences exist in mortality and LOS between patients who
receive CABG in the UK versus those who receive this
procedure in the US.
Primary Funding Source: Sollucient, LLC
• Recents Developments in Record Linkage in Health
Services Research in Australia
Cashel D'Arcy James Holman, MBBS, M.P.H., Ph.D., John
Bass, Ph.D., Diane Rosman, M.Sc.
Presented by: Cashel D'Arcy James Holman, MBBS, M.P.H.,
Ph.D., Professor of Public Health, School of Population
Health, Centre for Health Services Research, The University of
Western Australia, Perth, 6009; Tel: 61.8.9380.1251; Fax:
61.8.9380.1188; E-mail: darcy@sph.uwa.edu.au
Research Objective: To develop a population-based system
of linked administrative health records, research databases,
genealogical information and biospecimen data.
Study Design: The WA Record Linkage Project was firs
established in 1995 and uses computerised probabilistic
matching to provide links between over 30 major
administrative and research databases concerning health
status, service utilization and outcomes. The system is being
expanded through the inclusion of cross-jurisdictional data on
pharmaceutical and medical benefits held by the Australian
Commonwealth Government and by the inclusion of family
links and links to biospecimen data banks.
Population Studied: The population of Western Australia, an
Australian state of 1.8 million residents.
Principal Findings: The paper will overview the design of the
systems, applications to date (some 90 projects per year),
progress with new development and anticipated benefits.
Conclusions: Investment in research infrastructure of this
type at the national or state level enables an otherwise
impracticable and overly costly research agenda to proceed.
Implications for Policy, Delivery or Practice: The WA Record
Linkage Project and Family Connections Genealogical
Database will support a wide range of population-based health
services research and human genome epidemiology projects.
Primary Funding Source: National Health & Medical
REsearch Council of Austalia
• Prostate-Specific Antigen, Digital Rectal Examination and
Transrectal Ultrasonography: A Meta-Analysis for this
Diagnostic Triad of Prostate Cancer in Korea in
Symptomatic Men
Jae Man Song, M.D., Ph.D., Chun-Bae Kim, M.D., Ph.D., Hyun
Chul Chung, M.D.., Robert Kane, M.D., Ph.D.
Presented by: Chun-Bae Kim, M.D., Ph.D., Visiting Scholar
(Associate Professor), Clinical Outcomes Research Center
(Departments of Preventive Medicine), University of
Minnesota School of Pubic Health (Yonsei University Wonju
College of Medicine), D-351 Mayo (Box 197), 420 Delaware
Street, S.E., Minneapolis, MN 55455-0392; Tel: 612.625.7417;
Fax: 612.624.8448; E-mail: kimxx360@umn.edu
Research Objective: A meta-analysis was conducted using
results in the Korean literature with a focus on sensitivity and
specificity to determine whether prostate-specific antigen
(PSA) or digital rectal examination (DRE) or transrectal
ultrasonography (TRUS) provides the better diagnostic
outcome in possible prostate cancer patients.
Study Design: An extensive literature search of MedRIC
database et al (1980 to 2003) using the medical subject
headings “PSA”, “DRE”, and “TRUS”, as well as “prostate
cancer”, was performed. For the quantitative meta-analysis
process the methods of Hasselblad et al and SAS program
were utilized.
Population Studied: Of the 108 articles retrieved, 13 studies
(2,029 patients) were selected for this meta-analysis. The
criteria for quality evaluation were as follows: study subjects
must have been compared clinically for suspected prostate
cancer, and articles must include individual data about
sensitivity, specificity, and predictive value for the diagnostic
triad based on biopsy results as a reference standard.
Principal Findings: The pooled sensitivity, specificity, positive
predictive value, and negative predictive value for PSA greater
than 4ng/ml were 91.3%, 35.9%, 33.0%, and 92.3%,
respectively; and for PSA greater than 10ng/ml were 77.3%,
67.5%, 44.1%, and 89.9%, respectively; and for DRE were
68.4%, 71.5%, 45.0%, and 86.9%, respectively; and for TRUS
were 73.6%, 61.3%, 40.6%, and 86.6%, respectively.
According to the results in a fixed effect model in PSA criteria,
overall effect sizes for PSA4 and PSA10 were 0.8517 [95%
confidence interval (CI): 0.6694, 1.0340] and 1.0996 (95% CI:
0.9459, 1.2534). Also, according to the results using a random
effect model in both DRE and TRUS criteria, overall effect
sizes for DRE and TRUS were 0.8398 (95% CI: 0.7169, 0.9627)
and 0.8002 (95% CI: 0.6714, 0.9289). Also, the results on
positive predictive value for combination of PSA, DRE, and
TRUS in detecting prostate cancer jumped further to 68.3% or
76.8%.
Conclusions: In conclusion, this study suggests that prostatespecific antigen, digital rectal examination, and transrectal
ultrasonography for the diagnosis of prostate cancer were not
effective separately.
Implications for Policy, Delivery or Practice: Therefore, we
recommend that the urologists should use PSA together with
DRE and TRUS to diagnose for prostate carcinoma in patients
with primary lower urological symptoms.
Primary Funding Source: Grant from the Korean Urological
Association (2003)
• Evaluating the Productivity and Manpower of Chinese
Medicine Physicians in Taiwan
Jwo-Leun Lee, Ph.D., Jim-Shoung Lai, Ph.D.
Presented by: Jwo-Leun Lee, Ph.D., Associate Professor,
Health Care Administration, China Medical University
(Taiwan), 91 Hsueh Shih Road, Taichung, 404; Tel:
886.4.22053366 Ext. 7234; Fax: +886-4-22019901; E-mail:
jllee@mail.cmu.edu.tw
Research Objective: This study aims to evaluate the
productivity of Chinese medicine physicians in Taiwan
between 1992 and 2002, to construct a production function
and to lead some suggestions on manpower policy.
Study Design: A national sample of 208 and 291 Chinese
medicine physicians is interviewed in 1992 and 2002,
respectively. Diaries and questionnaires collect data.
Population Studied: A total of 300 and 500 Chinese medicine
physicians is sampled from the 1945 and 3617 practicing
Chinese medicine physicians in Taiwan in 1992 and 2002,
respectively.
Principal Findings: The Chinese medicine physicians in 2002
are younger, more educated and better trained than those in
1992. Their practicing time is 44.2 hours per week, 83% of it
spent on face-to-face contacting with patients, less by 10
hours for practicing but more by 3 hours for face-to-face
contacting than 1992. There are 252 visits per week per
physician, more than those in 1992 by 30%. The gross income
is therefore estimated to be 16 thousand US dollars per
month.
For the clinics, there are 4.2 physicians in one clinic and 3
assistants for each physician, about twice of those in 1992.
The capital input is estimated to be 9 thousand US dollars per
physician. The net income is therefore estimated to be 7
thousand US dollars per month.
In the production function, the elasticity of visits is estimated
to be 0.43 for physician labor, 0.39 for assistant labor, and
0.12 for clinic size. Other factors include physician age, rate of
the insured patients, and urbanization. Using the 1992
production function and 2002 variable values as a indicator of
potential productivity, the production is increased by 30%
between 1992 and 2002, but is still less than its potential
productivity by 40%.
Conclusions: It is suggested that Chinese medicine
physicians should be increased by 1.7% to 3.8% annually, in
which the former is the annual rate of Chinese medicine visits
and the latter the annual rate of the number of Western
medicine physicians in Taiwan. Yet both are less than the
actual rate of 4.6% for the annual increasing rate of Chinese
medicine physicians.
Implications for Policy, Delivery or Practice: The Ministry of
education and the Ministry of Health should consider a titer
policy to control the number of Chinese medicine physicians
in Taiwan.
Primary Funding Source: Ministry of Health, Taiwan
• Pharmaceutical Prices in Non-Industrialized Countries:
New Tools for Measurement, Analysis, and Action
Jeanne Madden, Ph.D., Andrew Creese, MA/M.Sc., Margaret
Ewen, Dennis Ross-Degnan, ScD, WHO/HAI Working Group
on Medicine Prices
Presented by: Jeanne Madden, Ph.D., Instructor, Department
of Ambulatory Care and Prevention, Harvard Medical School,
133 Brookline Avenue, 6th Floor, Boston, MA 02215; Tel:
617.509.9953; Fax: 617.859.8112; E-mail:
jeanne_madden@hphc.org
Research Objective: Pharmaceutical costs represent a larger
share of health spending in poorer countries and are usually
borne directly by patients. Drug prices are also a subject of
growing political controversy worldwide, and pose many
challenges to measurement and comparison. Few reliable
data are publicly available. A collaborative effort between the
World Health Organization and Health Action International
helps local researchers gather price data and present informed
analyses for policy making.
Study Design: Field surveyors collect patient prices on 30
common essential drugs from private sector pharmacies,
public clinics, and other facilities. Prices of the innovator
brand and two generic equivalents for each drug are taken
from at least 40 facilities. There is no independent
assessment of drug quality, but only nationally registered
drugs are included. Researchers enter price data in an
interactive spreadsheet which produces primary analyses,
including comparisons among products, product versions,
sectors, and geographic regions. Product availability is also
described. Information on international reference prices and
local mark-up structures and wages contribute to an
understanding of price patterns and their human impact.
Reference prices used are international non-profit bulk generic
wholesale.
Population Studied: Investigators conducted drug price
surveys in 10 pilot countries during 2001 and 2002: Armenia,
Brazil, Cameroon, Ghana, India, Kenya, Peru, Philippines,
South Africa, and Sri Lanka.
Principal Findings: Results varied considerably along several
dimensions. In Sri Lanka, median prices observed for the
individual innovator brand drugs surveyed in private
pharmacies ranged from 1 to 13 times the reference prices.
Medians for the same drugs in their most sold generic
versions ranged from 0.2 to 2 times the references. In Peru’s
private sector, for matched pairs of innovator brands and
generics, the ranges were 16 to 94 times the reference prices
and 2 to 77 times, respectively. Taking the median of medians
observed in Peru’s private sector, brand drugs cost about 3
times more than equivalent most-sold generics and 5 times
more than the cheapest generic equivalents. In Ghana,
generic hydrochlorothiazide and nifedipine were sold retail at 5
times and 9 times their respective reference prices.
Nonetheless, an unskilled government employee would have
spent half a day’s wage to pay for a month’s standard
hypertension treatment with generic hydrochlorothiazide and 5
days’ wages for similar treatment with generic nifedipine. In
US dollar terms, brand ranitidine cost almost 2.5 more in S.
Africa than in Armenia, and generic ranitidine cost over 11
times more. One month’s ulcer treatment with either brand
ranitidine or brand omeprazole cost about 2 months’ wages in
several African countries.
Conclusions: Comprehensive international price comparisons
are difficult because of differing market shares and availability.
However, large diffences in prices may be meaningful.
Analyses of price components indicate that local mark-ups
account for only a small portion of differences. Many drugs
were found retail-priced at 50 to 100 times the references and
far beyond patients’ ability to pay.
Implications for Policy, Delivery or Practice: Governments
and consumer groups can use data obtained with these
methods to illuminate problems in markets for drugs.
Opportunities to lower prices through generic substitution,
improved procurement strategies, and taxation changes are
evident.
Primary Funding Source: Rockefeller Foundation and Dutch
Foreign Aid
• Welcome Home: How Mexican Migrants Miss Out on
Retirement Benefits
Sara Ross, MPA/ID, Daniel Polsky, M.P.P., Ph.D., José Pagán,
Ph.D.
Presented by: Daniel Polsky, M.P.P., Ph.D., Research
Associate Professor, General Internal Medicine, University of
Pennsylvania, 423 Guardian Drive, 12th Floor, Philadelphia, PA
19104-6021; Tel: 215.573.5752; Fax: 215.573.8778; E-mail:
polsky@mail.med.upenn.edu
Research Objective: Recent policy initiatives address the
benefits afforded to the 8 million Mexican living in the United
States. Because these migrant workers may not also maintain
an engagement with the formal labor market in Mexico, they
risk forgoing the retirement benefits offered to elderly
Mexicans with sufficient years of work in Mexico. We explore
how time spent in the US affects the probability that elderly
Mexicans will receive retirement benefits.
Study Design: We use logistic regression to analyze the effect
of time spent in the US on two dependent variables: whether
the respondent has health insurance and whether he/she has
retirement pension benefits. We also evaluate the relationship
between migration and three other dependent variables:
whether the respondent had any doctor visits within the last
year prior to the interview, whether the respondent would visit
a formal health care provider for routine care, and the number
of doctor visits within the last year.
Population Studied: The study sample was drawn from the
Mexican Health and Aging Survey (MHAS). The MHAS
surveyed a representative sample of the 13 million Mexicans
born prior to 1951 and their spouses or partners, regardless of
age. For our sample, we include those over 65 who had ever
worked. The sample size is 3,972.
Principal Findings: While 53 percent of our sample receives
health insurance benefits, the probability that a migrant has
health insurance coverage is 4.3 percentage points lower.
Moreover, differences in health care utilization between
migrants and non-migrants arise due to the lack of health
insurance coverage rather than due to unobserved factors
related to the composition of the migrant and non-migrant
groups. Fifteen percent of elders in the sample receive
pension benefits. The probability of earning a pension
increases by 1.2 percentage points if they spend time in the
US. This result is driven almost wholly by Mexican elders who
gain US citizenship or permanent resident status and earn US
social security.
Conclusions: The relative disadvantages experienced by
Mexican elders who have a history of migration to the US—in
terms of access to health insurance—highlight the challenges
in extending retirement health insurance in the context of high
labor mobility. While migrants are able to partly substitute US
social security benefits for foregone Mexican social security,
there is no analogous substitution available to migrants when
it comes to health insurance.
Implications for Policy, Delivery or Practice: Policy
initiatives that aim to extend social security benefits to
migrant workers should not overlook retirement health
insurance. In the context of existing inequality in access to
health care, migration to the US threatens to further reduce
access to health care for aging Mexicans.
Primary Funding Source: NIA
• Resource Consumption and Operational Impact of SARS
in Taiwan Hospitals
Ming-Fong Chen, M.D., Ph.D., James Romeis, Ph.D., YuanTeh Lee, M.D., Ph.D.
Presented by: James Romeis, Ph.D., Professor, Health
Services Research, School of Public Health, Saint Louis
University, 3545 Lafayette Avenue, #300, St Louis, MO 63104;
Tel: 314.977.8148; Fax: 314.977.1674; E-mail: romeisjc@slu.edu
Research Objective: To assess resource consumption and
operational impact of SARS in Taiwan hospitals; discuss
appropriate operational and financial assistance that health
policy officials should provide to health care workers and
hospitals.
Study Design: Retrospective case-control, comparing claims
data and operational data for National Taiwan University
Hospital between April - June, 2002 [pre-SARS] with the
comparable SARS period data. We also surveyed physician
and nurse perceptions of their SARS-related workload intensity
and complexity.
Population Studied: 158 SARS patients compared to 527
pneumonia patients, controlling for gender, age and LOS
Principal Findings: Average treatment costs for SARS
patients were not higher than controls, although SARS patents
that expired incurred higher treatment costs. At its peak,
NTHU utilizaton rates decreased significantly: 71% inpatient,
63% outpatient and ED, 85% surgeries. Percieved intensity for
MDs declined with experience but incresed for nurses.
Conclusions: SARS caused severe financial and operational
losses for NTHU and other Taiwan hospitals. These losses
were not related to treatment costs but rather to externalities
associated with decreased utilzation. It also caused
significant burdens among treating MDs, but especially
nurses.
Implications for Policy, Delivery or Practice: Health policy
officals need to consider financial and other forms of
assitance for hospitals who treat epidemics similar to SARS or
bio-terrorism. In societies with NHI such as, these
mechanisms offset expected losses. In US hospitals, lossess
associated with externalities, place providers in a conflict
between mission, espertise and margin.
• Does Trade Affect Children?
Dov Rothman, Ph.D., David Levine, Ph.D.
Presented by: Dov Rothman, Ph.D., Assistant Professor,
Department of Health Policy and Management, Columbia
University, 600 West 168th Street, 6th Floor, New York, NY
10032; Tel: 212.342.4521; E-mail: dbr2104@columbia.edu
Research Objective: In this paper we ask whether openness
to the international economy affects infant and child mortality.
Study Design: We estimate the relationship between trade
and infant and child mortality using cross-national data
obtained from the World Bank’s World Development
Indicators. Because a simple correlation between trade and a
measure of children’s welfare does not necessarily reveal the
causal effect of trade, we first estimate a “gravity” model of
trade as a share of GDP. This uses exogenous geographical
characteristics to predict how much countries trade. We then
use the predicted geographic component of trade estimated
from the gravity model to obtain a cross-sectional estimate of
the effect of trade on children’s welfare.
We also analyze the time series of a panel of nations. This
approach allows us to estimate the relationship between trade
and children’s welfare controlling for time-invariant factors
that are specific to a nation. Because the predicted measures
of trade used in the cross-sectional analysis are based on
time-invariant geographical characteristics, our cross-sectional
identification strategy is not appropriate for a longitudinal
analysis. Thus, when using the panel we estimate a gravity
model that includes the GDP of nearby potential trading
partners. In this model, changes in our measure of predicted
trade are largely driven by changes in GDP in nearby nations.
Principal Findings: In the cross-section, we find that trade
predicts lower infant mortality and lower child mortality. Our
cross-sectional results imply that, for the average country, a 15percentage point increase in predicted trade as a share of
GDP (an increase of about one standard deviation)
corresponds to approximately 3 fewer infant deaths per 1000
births and 4 fewer infant deaths before age 5 per 1000 births.
In the panel analysis, we also find that increases in trade as a
share of GDP are associated with decreases in infant and child
mortality rates.
Conclusions: Our results suggest that trade does not have
the dire consequences sometimes ascribed to it by critics of
globalization. The general message of our findings is that
trade has a small but favorable impact on infant and child
mortality.
Implications for Policy, Delivery or Practice: It is widely
believed that openness to the international economy helps
countries become wealthier. At the same time, some argue
that openness to the international economy harms children,
and so protest against trade. Our results do not support this
policy position. Using relatively new econometric techniques,
we find that – if anything – trade helps children.
• Direct to Consumer Drug Advertising in New Zealand
Lynne Eagle, Ph.D., Dean Smith, Ph.D., Lawrence Rose, Ph.D.
Presented by: Dean Smith, Ph.D., Professor and Chair, Health
Management & Policy, University of Michigan, 109
Observatory, Ann Arbor, MI 48109-2029; Tel: 734.936.1196;
Fax: 734.764.4338; E-mail: deans@umich.edu
Research Objective: To assess the effects of DTC advertising
on patient and provider behavior in New Zealand, the only
country aside from the USA that permits DTC advertising of
drugs.
Study Design: A random sample of members of each of three
medical professional groups was obtained from a commercial
database. A stratified random sample of adult consumers was
drawn from the New Zealand Electoral roll. An eleven page,
64-item questionnaire was used, with many questions
containing subsections. Questions used were developed from
a range of sources, primarily the published literature and, with
permission the 1999 and 2000 FDA studies and the 2002
Prevention Magazine consumer study.
Population Studied: Physicians, pharmacists, nurses and
consumers in New Zeland
Principal Findings: Response rates: general practitioners
27%; pharmacists 29%; practice nurses 44%; and consumers
27.0%. GPs reported limited pressure to provide medications
and that customers were as likely to receive an alternative
medication or medical referral. Consultations with
pharmacists and nurses were predominantly concerned with
dosage and side effects issues. Attitudes towards customer
requests for DTC medications were generally positive and
similar across groups of medical professionals. However,
there were concerns that DTC advertising does not convey
sufficient information on the risks and negative effects of the
medication. There was substantial variation in responses
within each group of professionals, with some in support and
others opposed to DTC advertising, but with the majority
somewhat ambivalent. Overall consumer attitudes towards
DTC advertising were mixed, with a clear recognition both of
the information potential of the advertising, but also of its
shortcomings in providing balanced information.
Conclusions: Advertising was not seen either as placing a
burden on medical practices or causing tension between
patients and doctors.
Implications for Policy, Delivery or Practice: Results of
surveys in New Zealand paint a similar picture as those in the
United States, but with the effects - both positive and negative
- of, on average, half the magnitude.
Primary Funding Source: Massey University’s Academy of
Business Research Fund
• What Factors Affect London Nurses’ Decisions to Leave
Their Current Job and the Profession?
David Barron, Ph.D., Elizabeth West, Ph.D., Rachel Reeves,
Ph.D.
Presented by: Elizabeth West, Ph.D., Lecturer, Public Health,
London School of Hygiene and Tropical Medicine, G22 Kepple
Street, London, E-mail: elizabeth.west@lshtm.ac.uk
Research Objective: To investigate the relative importance of
interpersonal experiences at work, quality of care, and
satisfaction with pay and workload on nurses’ intention to
leave nursing or their current job, controlling for age, gender,
education and self-reported health.
Study Design: A postal survey using a questionnaire that was
initially developed in the US and adapted for use in UK acutecare settings by the authors. A multi-centre research ethics
committee granted ethical permission for the study. We
categorised respondents as “leavers” or “stayers” with regard
to their current job and the nursing profession, and used
logistic regression to estimate the effect of the independent
variables hypothesised to influence their employment choices.
Because respondents were grouped by hospital we used the
Huber-White method of estimating the standard errors.
Population Studied: Acute London hospitals were invited to
participate in the study because they typically have higher
turnover and vacancy rates than hospitals, and are more
reliant on temporary staff and overseas nurses than are
hospitals in other parts of the United Kingdom. Twenty
hospitals, divided between inner (11) and outer (9) areas of
the city agreed to participate. In the case of hospitals with less
than 400 nurses we surveyed the entire complement of staff.
In larger hospitals we drew a random sample of 300 nurses.
After two reminders, 2880 (out of 6160) useable responses
were returned, giving a response rate of 47%.
Principal Findings: We investigated whether a selection of
socio-demographic variables affected nurses’ employment
decisions and found that men were more likely to express an
intention to leave both their current job and the nursing
profession than were women. The effect of age changes over
the life course, but tends to fall year on year from the time that
nurses join the profession and rises again after about 40.
Those who rate themselves as having relatively good health
are more likely to intend to stay in nursing and in their current
job. Nurse assessed quality of care also has an impact on
both kinds of career decisions, as does their assessment of
their workload. High levels of satisfaction with pay lowers
nurses’ intention to leave their current job, but have a much
more significant negative impact on their intentions to leave
the profession. The experience of having been verbally or
physically abused by a patient or relative increases the
likelihood that a nurse will seek to quit both job and
profession. On the other hand, the perception that managers
listen to nurses’ views has a strong effect on retention in the
current job but is not significant in the model of quitting the
profession. A feeling of being valued by the hospital and by
society has an effect on nurses decisions to stay in the
profession, but is barely significant in the models of the
decision to leave the current job. Nurses who work in outer
London hospitals are much less likely to intend to leave their
current jobs than nurses who work in central London, but
there are no significant differences between the two groups in
terms of their intentions with regard to leaving the nursing
profession.
Conclusions: Nurses’ career decisions are complex and many
different variables contribute to the decision to leave or stay.
This study shows that controlling for personal characteristics
such as age, gender and health, nurses consider not only the
pay and conditions of the job, but also by the standards of
care that they see being delivered to patients. Inter-personal
relationships and the emotional climate in which nurses work
also play a role in the decision-making process.
Implications for Policy, Delivery or Practice: There are clear
indications of the mechanisms by which a viscous circle of
excessive workloads and declining standards could lead to
more attrition, which would in turn increase the workload of
remaining staff, and would threaten the quality of care.
Having to work even harder might then prompt even those
who would prefer to stay to seek another job. This study may
have different implications for national policy makers and local
managers. In the UK, where pay is mainly determined at a
national level, these results suggest that increasing nurses’
satisfaction with pay would have a dramatic effect on their
intentions to stay in the profession. National policy makers
might also note that nurses who feel valued by society are
more likely to be retained in the profession. Within individual
organisations, these results suggest that taking steps to
improve the quality of the emotional climate of the hospital
would pay dividends in terms of lowering turnover and
vacancy rates, which would probably also have a demonstrable
impact on quality of care.
Primary Funding Source: NHS R&D Programme
Invited Papers
The United States in a World Prescription Drug Market
Chair: William Scanlon, Ph.D.
Tuesday, June 8 • 11:15 a.m.-12:45 p.m.
•
Panelists: Gerard Anderson, Johns Hopkins University;
Anna Cook, Mathematica Policy Research, Inc.; Panos
Kanavos, London School of Economics and Political
Science; Bruce Stuart, University of Maryland at Baltimore
(no abstracts provided)