Assessing the pro-poor effect of different contracting schemes for health services on health facilities in rural Afghanistan. Miscoding: a threat to the hospital care system. How to detect it? Promotion of improvement as a science Eliciting public preference for health-care resource allocation in South Korea. Effect of Removing Direct Payment for Health Care on Utilisation and Health Outcomes in Ghanaian Children: A Randomised Controlled Trial An alternative strategy for studying adverse events in medical care Enhancing the comparability of costing methods: cross-country variability in the prices of non-traded inputs to health programmes Payment to healthcare professionals for patient recruitment to trials: systematic review and qualitative study. The doctor-patient relationship and malpractice. Lessons from plaintiff depositions. Exploring the transparency mechanism and evaluating the effect of public reporting on prescription: a protocol for a cluster randomized controlled trial Implementation of an audit with feedback knowledge translation intervention to promote medication error reporting in health care: a protocol Patient safety in developing countries: retrospective estimation of scale and nature of harm to patients in hospital The impact of an intervention to change health workers' HIV/AIDS attitudes and knowledge in Nigeria: a controlled trial. Defining and measuring health equity effects in research on task shifting interventions in high-income countries: a systematic review protocol Health Plan Members' Views about Disclosure of Medical Errors 'The public is too subjective': public involvement at different levels of health-care decision making. Effects of a Quality Improvement Collaborative on the Outcome of Care of Patients with HIV Infection: The EQHIV Study
BACKGROUND Despite progress in improving health outcomes in Afghanistan by contracting public health services through non-governmental organizations ( NGOs ) , inequity in access persists between the poor and non-poor . This study examined the distributive effect of different contracting types on primary health services provision between the poor and non-poor in rural Afghanistan . METHOD Contracts to NGOs were made to deliver a common set of primary care services in each province , with the funding agencies determining contract terms . The contracting approaches could be classified into three contracting out types ( CO-1 , CO-2 and CO-3 ) and a contracting-in ( CI ) approach based on the contract terms , design and implementation . Exit interviews of patients attending r and omly sample d primary health facilities were collected through systematic sampling across 28 provinces at two time points . The outcome , the odds that a client attending a health facility is poor , was modelled using logistic regression with a robust variance estimator , and the effect of contracting was estimated using the difference-in-difference approach combined with stratified analyses . RESULTS The sample covered 5960 interviews from 306 health facilities in 2005 and 2008 . The adjusted odds of a poor client attending a health facility over time increased significantly for facilities under CO-1 and CO-2 , with odds ratio of 2.82 ( 1.49 , 5.36 ) P-value 0.001 and 2.00 ( 1.33 , 3.02 ) P-value 0.001 , respectively . The odds ratios for those under CO-3 and CI were not statistically significantly different over time . When compared with the non-contracting facilities , the adjusted ratio of odds ratios of poor status among clients was significantly higher for only those under CO-1 , ratio of 2.50 ( 1.32 , 4.74 ) P-value 0.005 . CONCLUSIONS CO-1 arrangement which allows contractors to decide on how funds are allocated within a fixed lump sum with non-negotiable deliverables , and actively managed through an independent government agency , is effective in improving equity of health services provision BACKGROUND Artificially influencing the case mix of hospitals may have several deleterious consequences for the hospital care system . One distinguishes over-evaluation ( up-coding ) and under-evaluation ( under-coding ) of the case mix . Apart from its financial consequences , miscoding may cause a fracture in epidemiological time series and , by increasing artificially the severity of illness , may affect the assessment of the quality of hospital care , based on administrative data . METHODS Fixed effects models were used to assess deviant coding behavior  at the hospital level . To do so , we examined the linear evolution over time of characteristics such as length of stay and of 21 " triggering " conditions susceptible to increase the case mix of a stay . In case of deviant coding , these triggering conditions were checked to direct the audit towards fraud-suspected discharge abstract s. Hereto , a method consisting in comparing a single hospital 's linear evolution over time with the national linear evolution over time was developed , using an interaction term between linear evolution over time and hospitals . To test this methodology , fraud-directed audits were carried out in addition to the usual , at r and om audits . RESULTS Important inter-hospital differences in the linear evolution over time of several characteristics of Belgian hospitals were identified , as well as evidence not only of improving coding practice s , but also of up-coding , fraudulent under-coding and of numerous coding errors without financial impact . The coding errors , ascertained in the at r and om audit , result ed in a wrongful gain for the faulty hospitals of 28.23 days in 258 stays , whereas in case of fraud-directed audits these figures amounted up to 642.68 days in 334 stays . CONCLUSION Fraud-directed audit may constitute a valuable tool in the quality assurance of administrative data bases , improving their use in epidemiology and assessment of the quality of care The remarkable achievements of modern health care make the defi ciencies associated with delivery of care all the more noticeable . Health care is a major source of avoidable harm , and patients are routinely exposed to wide and inexplicable variations in the quality of care that they receive . These variations are very diffi cult to address , despite good intentions , policy focus , ambitious improvement programmes , and investment of re sources . A major reason for this diffi culty is that the urge to act can easily overwhelm the need for evidence to inform that action , to the extent that much quality improvement work is unscientifi c — it is neither informed by high- quality evidence , nor is it subject to rigorous assessment to establish its eff ectiveness , costs , and risks . Ironically , this absence of a scientifi c approach might lead to outcomes that are exactly the opposite of what is intended by improvement eff orts : re sources can be wasted , energy and enthusiasm are dissipated , the side-eff ects of interventions are ignored , and little positive change is evident . Adoption of a more scientifi c approach to improvement has great potential to enhance the ability of health systems to provide high- quality care and optimise re source use . We believe that the science of improvement is in what Kuhn calls the pre-paradigm phase of the emergence of a new discipline , one of the characteristics of which is the absence of an agreed defi nition . Attempts to create a defi nition can trigger intense debate , and the term improvement science has so far eluded consensus . Don Berwick and the Institute of Healthcare Improvement in Boston ( MA , USA ) have infl uenced one of the most common uses of this term , which is to describe applications of the approach developed by W Edwards Deming to reduce variation in industrial processes . The quality improvement move ment associated with these methods has made a valuable contribution , not least in challenging overly techno cratic , managerialist , or regulatory-focused approaches to change . However , this conceptualisation of a science of improvement is , by itself , too narrow and restrictive to address the challenges that face the health sector , and too often under-emphasises robust assessment . Percep tion of improvement solely in terms of imple mentation and comparative eff ectiveness research is similarly inadequate . An example of a benefi t of a broader way of thinking is the reduction of central line bloodstream infections in intensive-care units . These infections are a substantial and expensive clinical problem , and are often fatal . A cohort study of 103 intensive-care units in Michigan , USA , showed that a multicomponent programme of evidence -based technical interventions , adaptive interventions targeting culture and systems , and a central ised data collection and feedback system result ed in a substantial reduction in rates of these infections . These reductions were sustained over time and were associated with reduced mortality in participating intensive-care units compared with control units . The results have been replicated in 22 additional US states . Follow-up work investigated the mechanisms through which the programme worked , and generated a theory of change that could inform , and be tested in , subsequent repe titions of the programme . Another example of a benefi t of this broader way of thinking is the increase in identifi cation and referral of victims of domestic violence . Domestic violence is often managed inadequately , despite the major health and social implication s of unidentifi ed and unmanaged abuse . In a cluster-r and omised controlled trial in 51 primary care clinics in two UK cities ( London and Bristol ) , investigators tested a range of evidence -based interventions to increase rates of primary care identifi cation and referral to specialist advocacy services of women subjected to domestic violence . The results showed three-times more recorded disclosures of domestic violence and a 22-times higher number of referrals to specialist services in the intervention group . The interventions , in the form of targeted educational programmes , are now being adopted in several places in Engl and . These examples show some distinguishing features of a broader defi nition of improvement science . Improvement science aims to create practical learning that can make a timely diff erence to patient care . It is characterised by its large domain of interest , its applied nature , and its commitment to generation of practical learning that can be applied in real-life situations . Improvement science recognises and integrates many contributions , similar to the way that engineering science uses scientifi c knowledge and theories to address real-life problems . Improvement science also aims to generate local wisdom and generalisable or transferable knowledge , with robust , well established research methods applied in highly pragmatic ways . Improvement science enables local improvement and , crucially , produces knowledge with external validity . Thus , work classifi ed as improvement science should be of suffi cient quality to be published as a long-lasting , widely disseminated record in well-respected journals . Development of local knowledge based on a strong sense of ownership and a willingness to adapt improvement activities is clearly important , but too many quality improvement projects rely on contemporaneous , non-st and ardised , unverifi ed data to make judgments about their eff ectiveness . By contrast , the science of improvement is , based on moral and practical requirements , characterised by its commitment to rigorous and credible assessment methods Lancet 2013 ; 381 : OBJECTIVES To identify the principles the public considers important and the trade-offs between different values in health-care re source allocation practice s. METHODS This study approached the issue in both qualitative and quantitative ways . In a qualitative study , two focus groups discussed the issues of re source allocation in health care . To facilitate the discussion , a simple ranking task and a series of pairwise choice practice s were implemented . A discrete choice experiment survey question naire was also administered to a sample of the general population . Attributes and levels were determined through literature review s and the results from the focus group interview . We used a r and om-effect probit model to assess the effects of each attribute . RESULTS Through the focus group interviews , we found strong public support for the principle of equal opportunity . The participants thought that the severity of disease was the most important criterion when setting priorities . The majority supported the idea that the most disadvantaged should have the highest priority even when their health gains are less than those of others . The discrete choice experiment results showed that the severity of disease , health gains , and patients ' socioeconomic status significantly influence their choices , with each parameter having an expected sign . CONCLUSION The results showed that Koreans support not only health maximization but also equal opportunity , fair re source allocation , and e quality Background Delays in accessing care for malaria and other diseases can lead to disease progression , and user fees are a known barrier to accessing health care . Governments are introducing free health care to improve health outcomes . Free health care affects treatment seeking , and it is therefore assumed to lead to improved health outcomes , but there is no direct trial evidence of the impact of removing out-of-pocket payments on health outcomes in developing countries . This trial was design ed to test the impact of free health care on health outcomes directly . Methods and Findings 2,194 households containing 2,592 Ghanaian children under 5 y old were r and omised into a prepayment scheme allowing free primary care including drugs , or to a control group whose families paid user fees for health care ( normal practice ) ; 165 children whose families had previously paid to enrol in the prepayment scheme formed an observational arm . The primary outcome was moderate anaemia ( haemoglobin [ Hb ] < 8 g/dl ) ; major secondary outcomes were health care utilisation , severe anaemia , and mortality . At baseline the r and omised groups were similar . Introducing free primary health care altered the health care seeking behaviour of households ; those r and omised to the intervention arm used formal health care more and nonformal care less than the control group . Introducing free primary health care did not lead to any measurable difference in any health outcome . The primary outcome of moderate anaemia was detected in 37 ( 3.1 % ) children in the control and 36 children ( 3.2 % ) in the intervention arm ( adjusted odds ratio 1.05 , 95 % confidence interval 0.66–1.67 ) . There were four deaths in the control and five in the intervention group . Mean Hb concentration , severe anaemia , parasite prevalence , and anthropometric measurements were similar in each group . Families who previously self-enrolled in the prepayment scheme were significantly less poor , had better health measures , and used services more frequently than those in the r and omised group . Conclusions In the study setting , removing out-of-pocket payments for health care had an impact on health care-seeking behaviour but not on the health outcomes measured . Trial registration : Clinical Trials.gov ( # NCT00146692 ) BACKGROUND Data about the frequency of adverse events related to inappropriate care in hospitals come from studies of medical records as if they represented a true record of adverse events . In a prospect i ve , observational design we analysed discussion of adverse events during the care of all patients admitted to three units of a large , urban teaching hospital affiliated to a university medical school . Discussion took place during routine clinical meetings . We undertook the study to enhance underst and ing of the incidence and scope of adverse events as a basis for preventing them . METHODS Ethnographers trained in qualitative observational research attended day-shift , weekday , regularly scheduled attending rounds , residents ' work rounds , nursing shift changes , case conferences , and other scheduled meetings in three study units as well as various departmental and section meetings . They recorded all adverse events during patient care discussed at these meetings and developed a classification scheme to code the data . Data were collected about health-care providers ' own assessment s about the appropriateness of the care that patients received to assess the nature and impact of adverse events and how health-care providers and patients responded to the adverse events . FINDINGS Of the 1047 patients in the study , 185 ( 17.7 % ) were said to have had at least one serious adverse event ; having an initial event was linked to the seriousness of the patient 's underlying illness . Patients with long stays in hospital had more adverse events than those with short stays . The likelihood of experiencing an adverse event increased about 6 % for each day of hospital stay , 37.8 % of adverse events were caused by an individual , 15.6 % had interactive causes , and 9.8 % were due to administrative decisions . Although 17.7 % of patients experienced serious events that led to longer hospital stays and increased costs to the patients , only 1.2 % ( 13 ) of the 1047 patients made cl aims for compensation . INTERPRETATION This study shows that there is a wide range of potential causes of adverse events that should be considered , and that careful attention must be paid to errors with interactive or administrative causes . Healthcare providers ' own discussion s of adverse events can be a good source of data for proactive error prevention Background National and international policy makers have been increasing their focus on developing strategies to enable poor countries achieve the millennium development goals . This requires information on the costs of different types of health interventions and the re sources needed to scale them up , either singly or in combinations . Cost data also guides decisions about the most appropriate mix of interventions in different setting s , in view of the increasing , but still limited , re sources available to improve health . Many cost and cost-effectiveness studies include only the costs incurred at the point of delivery to beneficiaries , omitting those incurred at other levels of the system such as administration , media , training and overall management . The few studies that have measured them directly suggest that they can sometimes account for a substantial proportion of total costs , so that their omission can result in biased estimates of the re sources needed to run a programme or the relative cost-effectiveness of different choices . However , prices of different inputs used in the production of health interventions can vary substantially within a country . Basing cost estimates on a single price observation runs the risk that the results are based on an outlier observation rather than the typical costs of the input . Methods We first explore the determinants of the observed variation in the  prices  of selected  " non-traded " intermediate inputs to health programmes – printed matter and media advertising , and water and electricity – accounting for variation within and across countries . We then use the estimated relationship to impute average prices for countries where limited data are available with uncertainty intervals . Results Prices vary across countries with GDP per capita and a number of determinants of supply and dem and . Media and printing were inelastic with respect to GDP per capita , with a positive correlation , while the utilities had a surprisingly negative relationship . All equations had relatively good fits with the data . Conclusion While the preferred option is to derive costs from a r and om sample of prices in each setting , this option is often not available to analysts . In this case , we suggest that the approach described in this paper could represent a better option than basing policy recommendations on results that are built on the basis of a single , or a few , price observations OBJECTIVES To review UK guidelines regarding the use of financial incentives for healthcare professionals to become involved in clinical trials , and to survey perceptions and current practice . DATA SOURCES Electronic data bases were search ed from inception to June 2006 . Interviews were held with NHS healthcare professionals , research managers from the pharmaceutical industry and members of the public . REVIEW METHODS From the search es , 634 identified studies were assessed for inclusion in the systematic review , but only three met the criteria for data extraction . Fifty-eight individuals were interviewed : 38 chief investigators , six non- research active clinicians , eight public and six pharmaceutical managers . Investigators were selected from those funded by the HTA Programme , the other by ' snowballing ' and personal contact . RESULTS The evidence from the literature was limited and inconclusive . In UK guidelines , the issues around payments to clinicians or patients were implied rather than stated , usually linked to discussion of conflict of interest and disclosure of any such conflicts . Developments in NHS research governance had led to increased transparency in all payments for research participation and for payments to be made to NHS Trusts rather than individual clinicians . While reimbursement of costs incurred by research was strongly supported by the interviewees , payments to incentivise recruitment were not . A code of practice was suggested for payments in publicly funded trials , which was closely linked to the principles of Good Clinical Practice in research . Factors such as interest in the topic , scope for patient benefit and good communication were considered more important than payment . Interviews with the general public indicated low levels of awareness of the existence of payments to clinicians linked to patient recruitment in trials , and unanimous support for full disclosure . Interviews with managers in the pharmaceutical industry showed greater familiarity with payments for research involvement . GPs were seen as the only group for whom scope existed for individual payments . Concerns were expressed by the pharmaceutical company interviewees at the rising cost of research and unnecessary bureaucracy . CONCLUSIONS The ethical stances outlined in Good Clinical Practice in research were widely endorsed by the three groups interviewed . These allow reasonable payments to clinicians , subject to disclosure of any possible conflicts of interest . The potential for incentivising clinicians to recruit was limited as any payments should be based on the cost of inputs and should not be made to individuals but to their host organisation . NHS professionals were concerned that payments could damage the quality of research and also considered full disclosure to patients as challenging . Patients and members of the public favoured full disclosure and payment of expenses to patients involved in research . Pharmaceutical company interviewees viewed payment to the NHS for all research activities as normal and highly regulated . They complained that the prices charged were high and so variable that they required benchmarking . Considerable scope exists for compiling data on the factors that help and hinder the progress of clinical trials and also for experimenting with different incentives to encourage involvement in clinical research . Further research should focus on improved reporting of those organisational aspects of trials that are known to affect recruitment ; retrospective analysis of the factors associated with different levels of recruitment to RCTs ; prospect i ve comparative research on trial recruitment ; qualitative research on participants ' experiences of being involved in different kinds of trials , and proposals to include within trials experiments with payments methods BACKGROUND The current literature does not provide an answer to the question , " What prompts patients to sue doctors or hospitals ? " Not all adverse outcomes result in suits , and threatened suits do not always involve adverse outcomes . The exploration of other factors has been hampered by the lack of a methodology to contact plaintiffs and elicit their views about their experience in delivered health care . This study employed the transcripts of discovery depositions of plaintiffs as a source of insight into the issues that prompted individuals to file a mal practice cl aim . METHODS This study is a descriptive series review of a convenience sample of 45 plaintiffs ' depositions selected r and omly from 67 depositions made available from settled mal practice suits filed between 1985 and 1987 against a large metropolitan medical center . Information extracted from each deposition included the alleged injury ; the presence of the question , " Why are you suing ? " and , if present , the answer ; the presence of problematic relationship issues between providers and patients and /or families and , if present , the discourse supporting it ; the presence of the question , " Did a health professional suggest maloccurrence ? " and , if yes , who . Using a process of consensual validation , relationship issues were organized into groups of more generalized categories suggested by the data . Answers to the questions , " Why are you suing ? " and " Who suggested maloccurrence ? " are described . RESULTS Problematic relationship issues were identified in 71 % of the depositions with an interrater reliability of 93.3 % . Four themes emerged from the descriptive review of the 3787 pages of transcript : deserting the patient ( 32 % ) , devaluing patient and /or family views ( 29 % ) , delivering information poorly ( 26 % ) , and failing to underst and the patient and /or family perspective ( 13 % ) . Thirty-one plaintiffs were asked if health professionals suggested maloccurrence . Fifty-four percent ( n = 17 ) responded affirmatively . The post outcome -consulting specialist was named in 71 % ( n = 12 ) of the depositions in which maloccurrence was allegedly suggested . CONCLUSIONS In our sample , the decision to litigate was often associated with a perceived lack of caring and /or collaboration in the delivery of health care . The issues identified included perceived unavailability , discounting patient and /or family concerns , poor delivery of information , and lack of underst and ing the patient and /or family perspective . Particular attention should be paid to the postadverse-event consultant-patient interaction Background The public reporting of health outcomes has become one of the most popular topics and is accepted as a quality improvement method in the healthcare field . However , little research has been conducted on the transparency mechanism , and results are mixed with regard to the evaluation of the effect of public reporting on quality improvement . The objectives of this trial are to investigate the transparency mechanism and to evaluate the effect of public reporting on prescription at the level of individual participants . Methods / Design This study involves a cluster r and omized controlled trial conducted in 20 primary -care facilities ( clusters ) . Eligible clusters are those facilities with excellent hospital information systems and that have agreed to participate in the trial . The 20 clusters are matched into 10 pairs according to Technique for Order Preference by Similarity to Ideal Solution score . As the unit of r and omization , each pair of facilities is assigned at r and om to a control or an intervention group through coin flipping . Prescribed ranking information is publicly reported in the intervention group . The public material s include the posters of individuals and of facilities , the ranking lists of general practitioners , and brochures of patients , which are up date d monthly . The intervention began on 13th November 2013 and lasted for one year . Specifically , participants are surveyed at five points in time ( baseline , quarterly following the intervention ) through question naires , interviews , and observations . These participants include an average of 600 patients , 300 general practitioners , 15 directors , and 6 health bureau administrators . The primary outcomes are the transparency mechanism model and the changes in medicine-prescribe . Subsequently , the modifications in the transparency mechanism constructs are evaluated . The outcomes are measured at the individual participant level , and the professional who analyzes the data is blind to the r and omization status . Discussion This study protocol outlines a design that aims to examine the transparency mechanism and to evaluate the effect of public reporting on prescription . The research design is significant in the field of public policy . Furthermore , this study intends to fill the gap of the investigation of the transparency mechanism and the evaluation of public reporting on prescription Background Health professionals strive to deliver high- quality care in an inherently complex and error-prone environment . Underreporting of medical errors challenges attempts to underst and causative factors and impedes efforts to implement preventive strategies . Audit with feedback is a knowledge translation strategy that has potential to modify health professionals ’ medical error reporting behaviour . However , evidence regarding which aspects of this complex , multi-dimensional intervention work best is lacking . The aims of the Safe Medication Audit Reporting Translation ( SMART ) study are to:1 . Implement and refine a reporting mechanism to feed audit data on medication errors back to nurses2 . Test the feedback reporting mechanism to determine its utility and effect3 . Identify characteristics of organisational context associated with error reporting in response to feedback Methods / design A quasi-experimental design , incorporating two pairs of matched wards at an acute care hospital , is used . R and omisation occurs at the ward level ; one ward from each pair is r and omised to receive the intervention . A key stakeholder reference group informs the design and delivery of the feedback intervention . Nurses on the intervention wards receive the feedback intervention ( feedback of analysed audit data ) on a quarterly basis for 12 months . Data for the feedback intervention come from medication documentation point-prevalence audits and weekly reports on routinely collected medication error data . Weekly reports on these data are obtained for the control wards . A controlled interrupted time series analysis is used to evaluate the effect of the feedback intervention .  Self-report data are also collected from nurses on all four wards at baseline and at completion of the intervention to elicit their perceptions of the work context . Additionally , following each feedback cycle , nurses on the intervention wards are invited to complete a survey to evaluate the feedback and to establish their intentions to change their reporting behaviour . To assess sustainability of the intervention , at 6 months following completion of the intervention a point-prevalence chart audit is undertaken and a report of routinely collected medication errors for the previous 6 months is obtained . This intervention will have wider application for delivery of feedback to promote behaviour change for other areas of preventable error and adverse events Objective To assess the frequency and nature of adverse events to patients in selected hospitals in developing or transitional economies . Design Retrospective medical record review of hospital admissions during 2005 in eight countries . Setting Ministries of Health of Egypt , Jordan , Kenya , Morocco , Tunisia , Sudan , South Africa and Yemen ; the World Health Organisation ( WHO ) Eastern Mediterranean and African Regions ( EMRO and AFRO ) , and WHO Patient Safety . Participants Convenience sample of 26 hospitals from which 15 548 patient records were r and omly sample d. Main outcome measures Two stage screening . Initial screening based on 18 explicit criteria . Records that screened positive were then review ed by a senior physician for determination of adverse event , its preventability , and the result ing disability . Results Of the 15 548 records review ed , 8.2 % showed at least one adverse event , with a range of 2.5 % to 18.4 % per country . Of these events , 83 % were judged to be preventable , while about 30 % were associated with death of the patient . About 34 % adverse events were from therapeutic errors in relatively non-complex clinical situations . Inadequate training and supervision of clinical staff or the failure to follow policies or protocol s contributed to most events . Conclusions Unsafe patient care represents a serious and considerable danger to patients in the hospitals that were studied , and hence should be a high priority public health problem . Many other developing and transitional economies will probably share similar rates of harm and similar contributory factors . The convenience sampling of hospitals might limit the interpretation of results , but the identified adverse event rates show an estimate that should stimulate and facilitate the urgent institution of appropriate remedial action and also to trigger more research . Prevention of these adverse events will be complex and involves improving basic clinical processes and does not simply depend on the provision of more re sources The aim of the study was to improve health workers ' skills and confidence in dealing with patients with HIV disease and increase attention to patients ' human rights . A longitudinal controlled trial was carried out in which one Nigerian state served as the intervention site and the adjacent state served as the control site for an intervention and dissemination of training in clinical management , health education , and attitudinal change toward patients with HIV disease . The intervention group n=1072 , control group n=480 . Following initial question naire-defining focus groups , nurses , laboratory technologists and physicians in all base hospitals in the intervention state were trained by influential role models who attended the initial training . Data were collected in all sites pre-training and 1 y later . Hierarchical multiple regression analysis controlling for baseline data , and orthogonal factor analysis to define scales were used . Data showed significant positive changes after 1 y in the intervention group on perception of population risk assessment , attitudes and beliefs about people with HIV disease , less fear and more sympathy for and responsibility toward HIV patients , and an increase in self-perceived clinical skills . There was increased willingness to treat and teach colleagues about people with HIV . Clinician fear and discrimination were significantly reduced , and the climate of fear that was associated with HIV was replaced with a professional concern . There was increased underst and ing of appropriate psychosocial , clinical and human rights issues associated with HIV treatment and prevention . This intervention , targeting health workers in an entire state and using HIV/AIDS information , role modeling , diffusion of training and discussion s of discrimination and human rights , significantly affected the perception of risk groups and behaviors , perceived skills in treatment and counseling , reduced fears and increased concern for people with HIV disease , and improved the climate of treatment and prevention of HIV disease compared with a control state Introduction Task shifting interventions are intended to both deliver clinical ly effective treatments to reduce disease burden and address health inequities or population vulnerability . Little is known about how health equity and population vulnerability are defined and measured in research focused on task shifting . This systematic review will address the following questions : Among  task shifting interventions in high-income setting s that have been studied using r and omised controlled trials or variants , how are health inequity or population vulnerability identified and defined ? What methods and indicators are used to describe , characterise and measure the population ’s baseline status and the intervention ’s impacts on inequity and vulnerability ? Methods and analysis Studies were identified through data base search es ( MEDLINE , Embase , CINAHL , PsycINFO and Web of Science ) . Eligible studies will be r and omised controlled trials published since 2004 , conducted in high-income countries , concerning task shifting interventions to treat any disease , in any population that may face health disadvantage as defined by the PROGRESS-Plus framework ( place of residence , race/ethnicity/culture/ language , occupation , gender/sex , religion , social capital , socioeconomic position , age , disability , sexual orientation , other vulnerable groups ) . We will conduct independent and duplicate title and abstract screening , then identify related papers from the same programme of research through further data base and manual search ing . From each programme of research , we will extract study details , and definitions and measures of health equity or population vulnerability based on the PROGRESS-Plus framework . Two investigators will assess the quality of reporting and measurement related to health equity and vulnerability using a scale developed for this study . A narrative synthesis will highlight similarities and differences between the gathered studies and offer critical analyses and implication s. Ethics and dissemination This review does not involve primary data collection , does not constitute research on human subjects and is not subject to additional institutional ethics review or informed consent procedures . Dissemination will include open-access peer- review ed publication and academic conference presentations . PROSPERO Registration Number CRD42017049959 Context Disclosing medical errors is ethically appropriate , but its effect on the doctorpatient relationship and the likelihood of patients seeking legal advice is unknown . Contribution Clinical vignettes and question naires assessing patient opinion were mailed to members of a health maintenance organization . Each vignette varied the type of error , its severity , and the completeness of error disclosure . Respondents indicated that full disclosure improved trust , satisfaction , and emotional response . Decisions to seek legal advice were complex and were not necessarily deflected by full disclosure . Implication s While full disclosure improved patient satisfaction , it did not prevent or increase the likelihood of seeking legal advice . The Editors Since the publication of the Institute of Medicine 's report , To Err Is Human ( 1 ) , the problem of medical errors has gained increased recognition by the general public ( 2 ) . Research ers and policymakers have begun to focus serious efforts on improving patient safety ( 3 - 6 ) , but the complexity and uncertainty inherent in the practice of medicine make it unlikely that medical errors will ever be eliminated completely . When medical errors occur , effective physicianpatient communication is critical . Ethical and professional guidelines emphasize that physicians have a responsibility to disclose medical errors ( 7 - 9 ) , and recent st and ards link disclosure of adverse events to hospital accreditation ( 10 ) . There may also be pragmatic reasons for disclosure patients who pursue litigation may be motivated by a desire for a full explanation of the adverse event ( 11 - 13 ) , and patients may be less likely to sue physicians who provide full and honest explanations ( 14 ) . Although the preponderance of opinion is that disclosure is the right thing to do when a medical error has result ed in patient injury , disclosure often does not occur ( 15 - 20 ) . Several articles ( 21 - 33 ) and continuing medical education material s developed by national organizations ( 34 ) offer guidance , but there is limited empirical literature related to disclosure of medical errors to patients or families ( 11 - 20 , 35 - 41 ) . Of these articles , most focused on whether disclosure occurred or would occur ; few examined the disclosure process or the consequences of disclosure in any way . Thus , the lack of empirical research in this area may be a barrier to disclosure . We therefore undertook a study to assess patients ' views of disclosure . We surveyed a representative sample of members of a large health plan to measure responses to a set of 8 vignettes , each of which described a medical error , the clinical outcome of the error , and a physicianpatient dialogue about the event . The goals of the study were to examine the relationship of the error , severity of clinical outcome , and the level of disclosure to 5 dependent variables : likelihood of changing physicians , likelihood of seeking legal advice , patient satisfaction , trust , and emotional response . We also sought to determine patients ' attitudes , beliefs , and preferences about medical errors and disclosure in general . Methods Sample We conducted a mailed question naire survey of 1500 members of a New Engl and based health maintenance organization . Member names were r and omly sample d from a master list of all health plan members 21 to 85 years of age ( n = 130009 ) . Selected members were sent a letter indicating that they would be receiving the question naire , followed approximately 1 week later by the question naire . A $ 5 cash incentive was enclosed with the question naire . Nonrespondents were sent a reminder postcard 1 week later and a second copy of the question naire 1 week after . The response rate was calculated as the number of usable completed surveys returned ( 958 surveys ) divided by the number of mailed surveys ( 1500 surveys ) minus the number of surveys returned by the mail service as undeliverable ( 47 surveys ) . The study protocol was approved by the institutional review boards of the participating institutions . Question naire Design and Administration The question naire was developed on the basis of a systematic review of the literature ( 11 - 20 , 35 - 41 ) and the results of 2 focus groups comprising 14 patient volunteers . The question naire was refined after pretesting for length and comprehensibility . The final question naire , which is available from the first author , consisted of 4 sections : 1 ) a vignette describing a medication error and the clinical outcome of the error , followed by a physicianpatient dialogue about the error ; 2 ) items assessing participants ' response to the scenario and dialogue ; 3 ) items assessing attitudes , beliefs , and preferences about medical error and disclosure in general ; and 4 ) background and demographic items . Each section is described in detail in this paper . Vignettes and Dialogues Eight versions of the question naire were developed to produce a completely crossed factorial design with 2 levels each of the following variables : type of medication error ( inadequate monitoring of antiepileptic medication vs. prescribing penicillin when penicillin allergy is documented ) , clinical outcome of the error ( life-threatening outcome vs. less serious outcome ) , and level of physician disclosure about the error ( nondisclosure with limited information and responsibility vs. full disclosure with high information , responsibility , and promise to prevent recurrences ) . Figure 1 summarizes the vignette and dialogue combinations comprising each condition , and the Appendix presents them in detail . Each participant received only 1 version ; that is , a single error and outcome vignette with a corresponding dialogue wherein the physician and patient or family member discussed the error and its outcome . Distribution of versions was r and omized . Figure 1 . Description of conditions . Although most medical errors are considered systems errors ( 42 ) rather than the responsibility of individual providers , the actions of the treating physician may contribute to , or mitigate the results of , an error . Furthermore , the physician will often be consideredby the health care team and by the patientto be the most appropriate person to speak to the patient or family after an error has occurred ( 43 - 45 ) . We therefore chose vignettes in which the physician had direct involvement in the error and restricted our focus to the physician as communicator . These decisions were not intended to contradict the importance of a systems approach to patient safety or perpetuate a culture of blame , but rather to provide a starting point for study in this important area . Three items were included to assess whether the vignettes were effective in communicating as intended ; these items queried whether respondents perceived that an error had been made in each scenario and dialogue combination , whether the physician was perceived as responsible , and whether the error was perceived as preventable . Five response options were provided : strongly disagree , disagree , agree , strongly agree , and do n't know . Responses to the Vignette and Dialogue Respondents were instructed to imagine themselves as the patient or family member in the vignette and dialogue and to respond accordingly . Two items , developed for this study , focused on behavior . Respondents were asked to indicate whether they would change physicians or seek legal advice . The same 5 response options mentioned earlier were provided . For the analysis , responses were recoded to be dichotomous , with agree or strongly agree responses compared with all others . Patient satisfaction was assessed by using 5 items drawn from the American Board of Internal Medicine Patient Satisfaction Question naire ( 46 ) . Trust in the physician was assessed by using 8 items drawn from the Trust in Physician Scale ( 47 ) plus 1 supplemental item ( This doctor seemed to be withholding important information . ) . Item wording was modified slightly to refer to the vignette rather than a real encounter . Five semantic differential items were developed for this study to assess emotional response : angry or calm , frightened or reassured , worried or relieved , wronged or respected , and dissatisfied or satisfied . All were on a 5-point scale ; the most positive response option ( for example , reassured ) was assigned a value of 5 , and the most negative response option ( for example , worried ) was assigned a value of 1 . The variable emotional response was computed as the mean across the 5 semantic differential items , with higher scores indicating a more positive emotional response . Attitudes , Beliefs , and Preferences about Medical Error and Disclosure A set of 9 items was developed on the basis of the focus group interviews and a review of the literature to measure attitudes and beliefs about medical errors and disclosure in general . Five response options were provided : strongly disagree , disagree , neutral , agree , and strongly agree . Nine items were developed to assess respondents ' preferences for action after a medical error . These items were also based on the review of the literature on disclosure and were intended to directly assess preferences for commonly recommended responses to error ( for example , I would want to know the full details of how the error occurred . ) . Again , 5 response options were provided : strongly disagree , disagree , neutral , agree , and strongly agree . Background and Demographic Items Final items queried personal experience with medical error or injury , history of having filed a lawsuit against a physician or other health care provider , sex , education , age , and race or ethnicity . Statistical Analysis We compared background characteristics of respondents and nonrespondents by using a chi-square test for sex and a t-test for age . Associations between the 3 design variables ( type of medication error , severity of clinical outcome , and level of disclosure ) and the 2 dichotomously coded variables ( likelihood of changing physicians and likelihood of seeking legal advice ) were modeled by using logistic regression There are a number of impulses towards public participation in health care decision making including instrumentalist , communitarian , educative and expressive impulses and the desire for increased accountability . There has , however , been little research looking systematic ally at the public 's preferences for being involved in particular types of rationing decisions , nor indeed , has there been a critical examination of the degree of involvement desired by the public . The research reported here uses findings from focus groups and in-depth interviews to explore these questions . Eight focus groups were conducted with a total of 57 informants , four amongst r and omly selected members of the public and four with informants from health and non-health related organisations . Nineteen interviews were conducted to allow the elaboration of focus group comments , to probe views more deeply and to pursue emerging themes . The findings show variations in the willingness of members of the public to be involved in health care decisions and consistency across the different forms of the public as represented by the focus groups with r and omly selected citizens and pre-existing organisations . There was a strong desire in all the groups for the public to be involved both at the system and programme levels , with much less willingness to be involved at the individual level . At the system and programme levels informants generally favoured consultation , without responsibility for decisions , but with the guarantee that their contribution would be heard and that decisions taken following consultation would be explained . At the patient level informants felt that the public should participate only by setting criteria for deciding between potential beneficiaries of treatment . The public has much to contribute , particularly at the system and programme levels , to supplement the inputs of health care professionals Context Multi-institutional quality improvement collaboratives are popular , but are they effective ? Contribution This controlled study evaluated an HIV care Breakthrough Series program that emphasized provider teams , sessions on quality improvement theory and techniques , and report backs about implementing quality improvement . A review of the medical records of 9986 HIV-infected patients showed no important differences in  quality of care ( viral load suppression , pneumocystitis prophylaxis , and screening for tuberculosis and hepatitis ) between the 44 intervention clinics and the 25 control clinics . Caution s Patient adherence and satisfaction were not measured , and some control clinics may have used quality improvement techniques similar to those recommended by the collaborative program . The Editors In the pastdecade , tremendous improvements have occurred in measuring and monitoring the quality of medical care in the United States . Despite these advances , striking problems with quality persist ( 1 , 2 ) . The quality of care for patients with HIV infection is of particular concern . Substantial evidence shows that obtaining medical services and treatment for patients with HIV infection may lead to longer survival and better quality of life ( 3 , 4 ) , yet serious quality -of-care problems and striking disparities in quality by race and social class have been documented ( 4 - 6 ) . In the 1980s , continuous quality improvement techniques were introduced into health care ( 7 , 8) . These strategies emphasize that most quality problems are a result of system failings rather than problems with individual practitioners ( 9 ) . In 1995 , the Institute for Healthcare Improvement introduced the concept of the Breakthrough Series , which brings together health care organizations dedicated to improving the quality of care in particular clinical areas through the application of continuous quality improvement techniques ( 10 ) . These techniques ( known as Plan/Do/ Study /Act or PDSA cycles ; Figure 1 ) first identify deficiencies in quality , next repeatedly implement small-scale interventions and measure changes , and then refine and exp and interventions to improve processes of care ( 11 , 12 ) . Typically , each Breakthrough Series collaborative is composed of 20 to 40 participating health care organizations and a faculty with expertise in the clinical area and quality improvement methods ( 13 ) . To date , the Institute for Healthcare Improvement has conducted collaboratives with more than 700 teams working on 23 clinical conditions or treatment processes , including improving asthma care and reducing medication errors . Although some evaluations of quality before and after a collaborative support the validity of this approach , only a few limited controlled trials have been conducted ( 14 , 15 ) . Figure 1 . Theoretical construct of continuous quality improvement . An important source of funding for HIV care is the Ryan White Comprehensive AIDS Re sources Emergency ( CARE ) Act , which is administered by the HIV/AIDS Bureau of the Health Re sources and Services Administration . Title III of the CARE Act supports comprehensive primary health care for HIV-infected individuals and currently supports primary care services for more than 150000 patients receiving care in more than 200 community health centers , hospital-based clinics , and city or county health services ( 16 ) . In 1999 , the Health Re sources and Services Administration required all clinical sites that were newly awarded funding under Title III of the CARE Act to participate in a quality improvement collaborative conducted by the Institute for Healthcare Improvement . Other sites already receiving Title III funding were also invited to participate . This study evaluates the impact of the collaborative by examining pre- and postimplementation quality -of-care information on sample s of patients from both participating and matched nonparticipating clinics . Methods Study Site Selection and Controls Of the 200 Title III sites in the continental United States in May 2000 , we excluded 16 that reported caseloads of fewer than 100 cases per year , 12 that were initially slated to participate in the Breakthrough collaborative but elected not to do so , and 1 that lost its CARE Act funding shortly before the collaborative began . Of the remaining 171 sites , 62 participated in the collaborative . Among these sites , 54 agreed to participate in the study and 44 ( including 11 m and atory participants and 33 voluntary participants ; 71 % of collaborative participants ) provided chart review data . Of the 109 nonparticipating sites eligible to be selected as control sites , 65 provided information needed for matching . The potential control sites were matched with intervention sites on the basis of the type of site ( community health center , community-based organization , health department , hospital , or university medical center ) , location ( rural or urban ) , number of locations delivering care , region , and number of patients with active HIV infection . When these criteria were used , 40 sites were selected as potential controls and 37 of them ( 93 % ) agreed to participate in the study . Of these , 25 ( 63 % of potential control sites ) participated in the chart review portion of the study . The Committee on Human Studies of Harvard Medical School approved the study protocol . Quality Improvement Intervention Each participating clinic selected a team , usually consisting of at least one administrator and one or more clinicians , and a population of focus on which the team 's interventions would be tested . Usually , the population of focus consisted of all HIV-infected patients in a particular site , but participants sometimes chose to focus on a subset of patients , such as those under the care of a particular group of clinicians . Originally , the design of the collaborative extended for 12 months and included a kickoff meeting and 2 subsequent 2-day meetings called learning sessions . The kickoff learning session included instruction in the theory and practice of quality improvement by identifying problems in HIV care and then introducing the techniques of continuously implementing , measuring , and refining changes ( the Plan/Do/ Study /Act cycles ) ( 11 , 12 ) to improve the care of HIV-infected patients . Each learning session included additional instruction in quality improvement techniques and breakout sessions that focused on improving specific aspects of care , developing an information infrastructure to track progress , and specific aspects of quality improvement theory . In addition , teams exchanged ideas and presented storyboards of their progress to date . At each session , teams reported on activities , methods , and results . Toward the end of the 12-month period , the Health Re sources and Services Administration decided to extend the collaborative by 4 months and add a third learning session . Between the sessions ( action periods ) , team members implemented concepts and ideas . Each site had access to a collaborative listserve , participated in monthly conference calls with the collaborative faculty , and su bmi tted monthly reports of its improvements , which included charts that tracked the site 's improvements to date in the required key quality measures described in the next section . Detailed descriptions of the Breakthrough Series collaboratives are available elsewhere ( 10 , 17 - 19 ) . Quality -of-Care Monitors We selected quality -of-care measures ( Table 1 ) to coincide with required and optional quality measures selected by the collaborative faculty as areas for improvement . These measures were selected by the faculty after review ing the literature to identify areas of quality deficiency in the delivery of HIV care , particularly for underserved population s targeted by the CARE Act . Because of the paramount importance of antiretroviral therapy to the treatment of HIV infection , the faculty focused on measures related to antiretroviral treatment , including the percentage of patients receiving highly active antiretroviral therapy , the percentage of patients with a controlled viral load , and the percentage of patients who received adherence counseling , as required key measures for the collaborative . Measures were then developed on the basis of consensus guidelines appropriate for the period of care ( 20 ) . Our primary measures were rates of highly active antiretroviral therapy use and control of HIV viral load for appropriate patients . Patients eligible for highly active antiretroviral therapy included those with CD4+cell counts less than 0.350 109 cells/L , those with CD4+counts between 0.350 and 0.500 109 cells/L and a viral load greater than 5000 copies/mL , all patients with a viral load greater than 30000 copies/mL , and patients already receiving highly active antiretroviral therapy , as per the guidelines . We also assessed the use of  highly active antiretroviral therapy for those with CD4+counts less than 0.350 109 cells/L to reflect recommendations that were published after the end of the collaborative ( 21 ) . Because of the variability in viral load assays available at the time , viral load was considered controlled if it was undetectable or if the total viral load was less than 400 copies/mL. We also assessed the  use of screening and prophylaxis  , as well as  access to care .  The only key measure followed by the collaborative that we could not assess was related to adherence counseling because this information is not reliably available from medical records . Table 1 . Quality of Care Indicators * Quality -of-Care Data Collection To identify pre- and postintervention sample s of patients , we requested lists of all HIV-infected patients in care at each of the sites during the 2 time periods ( Figure 2 ) . For the first sample , sites were asked to provide encrypted lists of all HIV-infected patients age 18 years or older as of June 2000 seen at the site between 1 January and 30 June 2000 . For the second sample , sites were asked to provide a similar list of active patients age 18 years or older as of
Authors ' conclusions There is a paucity of evidence regarding how best to reduce corruption .
Promising interventions include improvements in the  detection and punishment of corruption  , especially efforts that are coordinated by an independent agency .
Other promising interventions include guidelines that prohibit doctors from accepting benefits from the pharmaceutical industry , internal control practice s in community health centres , and increased transparency and accountability for co-payments combined with reduced incentives for informal payments .
Key messages The review suggests that some strategies to fight corruption in the health sector can have an effect on corruption .
This study shows that these strategies may have led to fewer patients giving their doctors informal payments ( low certainty evidence ) . •
The study suggests that this may have changed doctors ' attitudes about the influence of pharmaceutical companies on their choice of medicines ( low certainty evidence ) . •
We do n't know what the effects of these strategies have on healthcare or people 's health , or if these strategies had any harmful effects .
Background Corruption is the abuse or complicity in abuse , of public or private position , power or authority to benefit oneself , a group , an organisation or others close to oneself ; where the benefits may be financial , material or non- material .
It is wide-spread in the health sector and represents a major problem .
Objectives Our primary objective was to systematic ally summarise empirical evidence of the effects of strategies to reduce corruption in the health sector .
Our secondary objective was to describe the range of strategies that have been tried and to guide future evaluations of promising strategies for which there is insufficient evidence .
The extent to which increased transparency alone reduces corruption is uncertain .
Interventions to reduce corruption in the health sector What is the aim of this review ?
The aim of this Cochrane review is to assess the effectiveness of strategies to reduce corruption in the health sector .
Corruption can occur in any area of the health sector , and happens when people abuse their own position to benefit themselves , their organisation , or other people close to them .
It can take many forms , including bribes , theft , or giving incorrect or inaccurate information deliberately .
It can take money away from healthcare , lead to poorer quality care and make access to healthcare unfair , and often affects poor people the hardest .