Journal of Health Services Research & Policy

Patients with a combination of long-term physical health problems can face barriers in obtaining appropriate treatment for co-existing mental health problems. This paper evaluates the impact of integrating the improving access to psychological therapies services (IAPT) model with services addressing physical health problems. We ask whether such services can reduce secondary health care utilization costs and improve the employment prospects of those so affected.

We used a stepped-wedge design of two cohorts of a total of 1,096 patients with depression and/or anxiety and comorbid long-term physical health conditions from three counties within the Thames Valley from March to August 2017. Panels were balanced. Difference-in-difference models were employed in an intention-to-treat analysis.

The new Integrated-IAPT was associated with a decrease of 6.15 (95% CI: −6.84 to −5.45) [4.83 (95% CI: −5.47 to −4.19]) points in the Patient Health Questionnaire-9 [generalized anxiety disorder-7] and £360 (95% CI: –£559 to –£162) in terms of secondary health care utilization costs per person in the first three months of treatment. The Integrated-IAPT was also associated with an 8.44% (95% CI: 1.93% to 14.9%) increased probability that those who were unemployed transitioned to employment.

Mental health treatment in care model with Integrated-IAPT seems to have significantly reduced secondary health care utilization costs among persons with long-term physical health conditions and increased their probability of employment.

To identify barriers created and maintained by the health system affecting engagement in a family-based multidisciplinary healthy lifestyle programme for children and adolescents in New Zealand.

We conducted 64 semi-structured interviews with participants of the programme (n = 71) with varying levels of engagement, including those who declined contact after their referral. Half the interviews were with families with Māori children, allowing for appropriate representation. Interviews were analysed using thematic analysis.

Five health system factors affecting engagement were identified: the national policy environment, funding constraints, lack of coordination between services, difficulty navigating the health system, and the cost of primary health care.

Engaging with a health system that creates and maintains substantial barriers to accessing services is difficult, affecting programme engagement, even where service-level barriers have been minimised. Lack of access remains a crucial barrier to improved health outcomes for children and their families experiencing childhood obesity in New Zealand. There is a need for comprehensive approaches that are accompanied by a clear implementation strategy and coordinated across sectors.

To investigate the effects of an admission avoidance pathway within a new integrated respiratory service on the number of Chronic Obstructive Pulmonary Disease (COPD)-related hospital admissions in England.

We used interrupted time series analysis to estimate the effects of the admission avoidance pathway on COPD hospital admissions, length of stay, and 30-day readmissions. We included all unplanned admissions with COPD as primary diagnosis using Hospital Episode Statistics, comparing the intervention region with a demographically similar control region in the two years before and one year after the implementation of the new service.

Unplanned hospital admissions for COPD exacerbations followed a clear seasonal pattern, peaking in early winter. We found no evidence that the admission avoidance pathway influenced the rate of hospital admissions or 30-day readmissions. We found weak evidence of a trend change in length of stay following the launch of the admission avoidance pathway.

Our study adds to the growing body of evidence that suggests that additional admission avoidance capacity alone does not lead to a measurable reduction in admissions or length of stay. Further investigation is required to understand the reasons why. A longer follow-up may be required to see some of the potential benefits.

To demonstrate the challenges of interpreting cross-country comparisons of paediatric asthma hospital admission rates as an indicator of primary care quality.

We used hospital administrative data from >10 million children aged 6–15 years, resident in Austria, England, Finland, Iceland, Ontario (Canada), Sweden or Victoria (Australia) between 2008 and 2015. Asthma hospital admission and emergency department (ED) attendance rates were compared between countries using Poisson regression models, adjusted for age and sex.

Hospital admission rates for asthma per 1000 child-years varied eight-fold across jurisdictions. Admission rates were 3.5 times higher when admissions with asthma recorded as any diagnosis were considered, compared with admissions with asthma as the primary diagnosis. Iceland had the lowest asthma admission rates; however, when ED attendance rates were considered, Sweden had the lowest rate of asthma hospital contacts.

The large variations in childhood hospital admission rates for asthma based on the whole child population reflect differing definitions, admission thresholds and underlying disease prevalence rather than primary care quality. Asthma hospital admissions among children diagnosed with asthma is a more meaningful indicator for inter-country comparisons of primary care quality.

In recent years there has been a proliferation of patient safety policies in the United Kingdom triggered by well publicized failures in health care. The Learning from Deaths (LfD) policy was implemented in response to failures at Southern Health National Health Service (NHS) Foundation Trust. This study aims to develop a narrative to enable the understanding of the key drivers involved in its evolution and implications for future national patient safety policy development.

A qualitative study was undertaken using documentary analysis and semi-structured interviews (n = 12) with policymakers from organizations involved in the design, implementation and assurance of LfD at a system level. Kingdon’s Multiple Streams Approach was used to frame the policymaking process.

The publication of the Southern Health independent review and subsequent highlighting by the Care Quality Commission of a fragmented approach to learning from deaths across the NHS opened a ‘policy window.’ Under the influence of the families affected by patient safety failures and the then Secretary of State, acting as ‘policy entrepreneurs,’ recently developed methods for mortality review were combined with mechanisms to enhance transparency and governance. This rapidly created a framework designed to ensure NHS organizations identified remedial safety problems and could be accountable for addressing them.

The development of LfD exhibits several common features with other patient safety policies in the NHS. It was triggered by a crisis and the need for a prompt political response and attempts to address a range of concerns related to safety. In common with other safety policies, LfD contains inherent tensions related to its primary purpose, which may hinder its impact. In the absence of formal evaluations of these policies, deeper understanding of the policymaking process offers the possibility of identifying potential barriers to goal achievement.

The United States’ Institute of Medicine recommends that health care providers be aware of sex trafficking (ST) indicators and conduct risk assessments to identify people at risk. However, the challenges among those who conduct such assessments remain largely understudied. The aim of this study was to understand the perceived barriers to ST risk assessment among health care providers in a large health care organization.

This study used a collective case study approach in five sites of a large health care organization that serves high-risk populations in a Midwestern state. Twenty-three in-depth, semi-structured interviews were conducted with health care staff (e.g. medical assistants, nurse practitioners). Two research team members conducted independent deductive coding (e.g. knowledge of ST), and inductive coding to analyse emerging themes (e.g. responses to ST risk or commercial sex disclosures, provider role ambiguity).

Although staff routinely screened by asking ‘Have you ever traded sex for money or drugs?’, participants primarily described avoiding further discussions of ST with adult patients because they (1) aimed to be non-judgmental, (2) viewed following up as someone else’s job, and/or (3) lacked confidence to address ST concerns themselves, particularly when differentiating sex work from ST. Differences all emerged based on clinical context (e.g. urban location).

There may be missed opportunities to assess patients for ST risk and use harm-reduction strategies or safety plan to address patients’ needs. Implications for practice, policy, and future research are discussed.

Patients accommodated in single-bed rooms may have a reduced risk of hospital-acquired infections (HAIs) compared to those in multi-bed rooms. This study aimed to examine the effect of single-bed accommodation on HAIs in older patients admitted to a geriatric ward.

A retrospective cohort study of patients admitted to geriatric wards in a university hospital in Central Denmark Region linked to a move to a newly built hospital, involving all consecutively admitted patients aged 65 years and over from 15 September to 19 December 2016 and a similar cohort admitted in the same three months in 2017. We compared the incidence of HAIs in patients in single-bed accommodation to those in multi-bed accommodation using retrospective review of electronic patient records, with all infections verified microbiologically or by X-ray with onset between 48 hours after admission to 48 hours after discharge from hospital.

In total 446 patients were included. The incidence of HAIs in multi-bed accommodation was 30% compared to 20% in single-bed accommodation. The hazard ratio was 0.62 (95% Confidence Interval 0.43–0.91, p = 0.01) for single-bed accommodation. This finding remained robust after adjustment for age, sex, infection at admission, risk of sepsis, use of catheter, treatment with prednisone or methotrexate, and comorbidity index.

Accommodation in single-bed rooms appeared to reduce HAIs compared to multi-bed rooms in two geriatric wards. This finding should be considered as hypothesis-generating and be examined further using an experimental design.

To review the evidence of the effects of centralization of cancer surgery on postoperative mortality.

We searched Medline, Embase, Cinahl, Cochrane and Scopus (up to November 2019) for studies that (i) assessed the effects of centralization of cancer surgery policies on in-hospital or 30-day mortality, or (ii) described changes in both postoperative mortality for a surgical intervention and degree of centralization using reduction in the number of hospitals or increases in the proportion of patients undergoing cancer surgery at high volume hospitals as proxy. PRISMA guidelines were followed. We estimated pooled odds ratios (OR) and conducted meta-regression to assess the relationship between degree of centralization and mortality.

A total of 41 studies met our inclusion criteria of which 15 evaluated the effect of centralization policies on postoperative mortality after cancer surgery and 26 described concurrent changes in the degree of centralization and postoperative mortality. Policy evaluation studies mainly used before-after designs (n = 13) or interrupted time series analysis (n = 2), mainly focusing on pancreatic, oesophageal and gastric cancer. All but one showed some degree of reduction in postoperative mortality, with statistically significant effects demonstrated by six studies. The pooled odds ratio for centralization policy effect was 0.68 (95% Confidence interval: 0.54–0.85; I² = 80%). Meta-regression analysis of the 26 descriptive studies found that an increase of the proportion of patients treated at high volume hospitals was associated with greater reduction in postoperative mortality.

Centralization of cancer surgery is associated with reduced postoperative mortality. However, existing evidence tends to be of low quality and estimates of the effect size are likely inflated. There is a need for prospective studies using more robust approaches, and for centralization efforts to be accompanied by well-designed evaluations of their effectiveness.