Laura Guadalupe González Ortiz

Disentangling spillover effects of antibiotic consumption: a spatial panel approach

Literature on socioeconomic determinants of antibiotic consumption in the community is limited to few countries using cross-sectional data. This article analyses regional variations in outpatient antibiotics in Italy using a balanced panel dataset covering the period 2000 to 2008. We specify an econometric model in which antibiotic consumption depends upon demographic and socioeconomic characteristics of the population, the supply of health care services in the community, and antibiotic copayments. The model is estimated by means of Ordinary Least Squares (OLS) techniques with Fixed Effects (FE). The implications of consumption externalities across geographical areas are investigated by means of Spatial-Lag and Spatial-Error models (SLFE and SEFE). We find significant and positive income elasticity and negative effects of copayments. Antibiotic use is also affected by the age structure of the population and the supply of community health care. Finally, we find evidence of spatial dependency in the use of antibiotics across regions. This suggests that regional policies (e.g. public campaigns) aimed at increasing efficiency in antibiotic consumption and controlling bacterial resistance may be influenced by policy makers in neighbouring regions. There will be scope for a strategic and coordinated view of regional policies towards the use of antibiotics.

Organizing healthcare in remote rural areas: Comparing experiences of service delivery re-design

Abstract Background: The debate about closing small hospitals located in rural and/or remote areas is not novel. However, demographic and epidemiologic trends, together with technologic advances are associated with emerging clusters of complex patients. Rural and/or remote areas tend to anticipate the national demographic forecasts. Therefore, concerns about appropriate health services accessibility are legitimate. Method: We selected three cases of health service delivery in rural and/or remote areas resulting from reorganization of previously existing hospitals: two cases are located in Switzerland and one in Italy. Semi-structured interviews were conducted in each organization, where researchers collected also official documents. Each researcher coded the data independently. Then codes were iteratively discussed to identify common dimensions suitable for comparison across the cases. Discussion: The comparative analysis showed that the apparent contrast between social/health and policy/managerial instances has reached a point of equilibrium. The reorganization processes can be interpreted as an optimization of the coordination of the health and social resources available within and close to the community. The existence of a leading reference subject, human resource management, and logistic arrangements played an important role in the success of the initiatives.

The Development, Description and Appraisal of an Emergent Multimethod Research Design to Study Workforce Changes in Integrated Care Interventions

Introduction: In this paper, we provide a detailed and explicit description of the processes and decisions underlying and shaping the emergent multimethod research design of our study on workforce changes in integrated chronic care. Theory and methods: The study was originally planned as mixed method research consisting of a preliminary literature review and quantitative check of these findings via a Delphi panel. However, when the findings of the literature review were not appropriate for quantitative confirmation, we chose to continue our qualitative exploration of the topic via qualitative questionnaires and secondary analysis of two best practice case reports. Results: The resulting research design is schematically described as an emergent and interactive multimethod design with multiphase combination timing. In doing so, we provide other researchers with a set of theory- and experience-based options to develop their own multimethod research and provide an example for more detailed and structured reporting of emergent designs. Conclusion and discussion: We argue that the terminology developed for the description of mixed methods designs should also be used for multimethod designs such as the one presented here.

Barriers and Facilitators to Workforce Changes in Integrated Care

Introduction: The aim of the study is to investigate the barriers and facilitators to the implementation of workforce changes implemented as part of integrated chronic care interventions. Methods: We used a qualitative multimethod design that combined expert questionnaires, a systematic literature review, and secondary analysis of two case reports. Twenty-five experts, twenty-one studies and two case reports were included in the study. Results: Most barriers related to problematic delivery structures, health professionals’ skills and enthusiasm, IT, funding, culture and cooperation and communication. Most facilitators related to health professionals’ motivation and enthusiasm, good delivery structures, communication and cooperation, IT, patients, leadership and senior management. Overall, similar categories of barriers and facilitators were found. Discussion: We recommend that future research focusses on more complex designs including multiple data sources, as these are better able to capture the complexity of interventions such as integrated care. We recommend that health managers and policy-makers should invest in delivery structures and skills and motivation of health professionals to improve the implementation of workforce changes in integrated chronic care interventions. Conclusion: The added value of the present study lies in its provision of information on which factors might mitigate the success of an intervention, which helps to prevent premature conclusions of ineffectiveness for complex interventions.

Exploration of workforce changes in integrated chronic care : Findings from an interactive and emergent research design

Introduction Integrated care interventions introduced in response to the increased demand for long-term care entail profound changes to the health workforce. This exploratory study aims to provide an overview of the workforce changes implemented as part of integrated chronic care interventions. Methods An interactive and emergent research design was used consisting of a literature review, qualitative expert questionnaires and case reports. We defined integrated care as interventions targeting at least two of the six Chronic Care Model components. Workforce changes were defined as those changes experienced by clinical and non-clinical staff responsible for public and individual health intervention. Results Seven workforce changes were identified: (1) nurse involvement, (2) multidisciplinary staff, (3) multidisciplinary protocols/pathways, (4) provider training, (5) case manager/care coordinator, (6) team meetings, and (7) new positions. Most interventions included more than one of these workforce changes. Conclusion The results of this study provide detailed insights into the current implementation of workforce changes in integrated care interventions and thereby pave the way for further investigations into the relative effectiveness of different workforce changes within the scope of complex interventions. Advancing knowledge in this area is essential for fostering health systems’ capacity to cope with the challenges related to the current demographic and epidemiological trends.