BMC Health Services Research

It is critical to calculate correctly the costs of implementing health interventions to generate reliable budgets, perform planning functions (including staff planning), and conduct economic evaluations. With the recent decrease in funding for international development assistance for health and the emphasis on country-led implementation of health programs in low- and middle-income countries, understanding the true cost of providing health services is even more important. As responsibility for funding and delivering health services shifts, inaccurate cost estimates can result in under-resourced disease response programs, ultimately lowering health outcomes. Costing studies, which aim to provide details on the financial and human resources necessary to deliver health services, rarely account for the time healthcare providers spend preparing for patient visits or following up with patients after a visit is complete. This deficiency in cost data is often acknowledged by researchers but seldom corrected, and consequently health policymakers do not know the true cost of staffing health facilities. In this paper, we present an updated methodology on how non-client-facing and non-clinical provider time should be incorporated into activity-based costing and management (ABC/M) applications. These methods are also applicable to traditional time-motion costing studies, including survey instrument changes and changes in calculating provider and operational costs. We present and discuss illustrative results which indicate that provider costs could increase by approximately 50% when non-client-facing provider time is included; operational costs could also increase, but likely by a smaller percentage. It is encouraging that we now have a simple, low-cost fix to the important issue of including provider costs correctly in both ABC/M and time-motion costing applications.

ContextFamily and Group Conferencing (FGC) is a strengths-based approach to social work, originating from New Zealand and now used internationally. Previous research on FGC has focused largely on the context of childrens services but, FGC also aligns with the principle of the Care Act in England to prevent, reduce or delay the need for long-term (and potentially costly) adult care services. Limited previous research has tended to explore potential cost savings associated with FGC, without accounting for the cost of the intervention itself, risking biased results. ObjectiveThis paper aims to identify resource use and associated monetary costs associated with FGC services in English adult social care and mental health settings. MethodsFramework development was informed by previously published work establishing programme theory for FGC, extended by expert opinion and published sources of monetary costs. The framework used scenario-based analysis and a bottom-up costing approach, with sensitivity analysis. ResultsEstimated costs of conducting a standard full FGC (excluding referral) range from {pound}1,455 to {pound}2,043 (adjusted from 2022-2023 to 2025 prices) from a local authority and National Health Service (NHS) perspective. Costs can vary depending on the involvement of an advocate or interpreter, network size and the complexity of issues being addressed. DiscussionHigher staff costs in the UK account for slightly higher intervention costs in an NHS mental health than in an adult social care context. ConclusionReallocating scarce public resources with the intention of preventing, reducing or delaying use of costly future care must be evidence-based as pressures build to meet acute needs. Accurate per-case costing of FGC is a necessary preliminary step towards exploring the cost-effectiveness of FGC. A full economic evaluation will account for costs, outcomes, and alternative options (uses of limited resources). Ethics StatementUsing the UK Health Research Authority (HRA) screening tool, it was determined that the wider research project did not constitute research for which HRA approval was necessary, and therefore ethical approval (for the wider research project) was obtained from the University of Birmingham Humanities and Social Sciences Ethical Review Committee (ERN_22-0818). Research reported in this paper did not involve any human participants, or the processing or analysis of any human/personal data. Our research was informed by published sources (including grey literature) and expert opinion from practitioners partnering with us to deliver the research.

BackgroundWith the global focus on task-sharing initiatives to bridge the treatment gap, the assessment of competencies of non-specialists is essential. The ENhancing Assessment of Common Therapeutic factors (ENACT) was developed to assess the competence of non-specialists to deliver psychosocial interventions, but the evidence regarding its application, implementation and adaptation process is limited. The present study aims to fill this gap by adapting and pilot testing the ENACT tool for resource-constrained settings. Methods and ResultsWe used a sequential, mixed-methods approach to adapt and pilot test the ENACT tool for evaluating therapeutic skills of non-specialists trained in mhGAP trainings. The adaptation process consisted of selection of competencies through literature review and focus group discussion. This was followed by designing a test strategy comprising development of a case vignette, its iterative refinement and adapting scoring framework. Lastly, feasibility was tested in the mhGAP workshop setting. Eight competencies were retained based on their relevance, comprehensibility and feasibility. Each competency was rated on a four-point ordinal scale, with level 1 indicating no skill, while 2, 3 and 4 reflecting some, all and advanced skills, respectively. Role-plays were video-recorded and rated by trained raters. Good inter-rater reliability and significant correlation between competencies were observed. Discussion/ConclusionENACT can be used to assess therapeutic skills but must be paired with structured rater training and contextual adaptation. Our study addressed its implementation challenges by making it manageable with limited resources, time and raters, making it scalable for low-resource settings. Our findings can inform mhGAP training design and delivery, facilitate in shifting its emphasis from a biomedical centered training to patient-centered approach. It can also guide curriculum refinement, identify priority skill areas for refresher trainings, and serve as mechanism for quality improvement for training and supervision. Lastly, it can inform policy decisions to integrate foundational competencies into large-scale training and supervision systems.

This research investigates the effects of financial and operating costs and service delivery efficiency within selected Integrated Care Boards (ICBs) in the UK. Utilising a comprehensive dataset, the study employs both regression analysis and Data Envelopment Analysis (DEA) to evaluate the impact of key independent variables of staff cost, efficiency savings, liquidity ratio, interest on lease liabilities, population size, fund, staff turnover, estate investment level, and right-of-use assets on two critical dependent variables (patient waiting time and operating surplus/deficit). The regression analysis reveals significant effects, highlighting the positive impact of population size and staff turnover on patient waiting times, and the positive correlation between right-of-use assets and operating surplus. Conversely, efficiency savings and increased funding are found to significantly reduce patient waiting times. The DEA identifies variations in efficiency across different ICBs, pinpointing those operating on the efficiency frontier and those with room for improvement. The findings offer valuable insights for policymakers and healthcare managers aiming to optimise resource allocation, enhance operational efficiency, and ultimately improve patient outcomes within the evolving landscape of integrated care in the UK.

Non-profit, faith-based providers (FBPs) play a major role in primary care delivery across Sub-Saharan Africa and are increasingly integrated into national health systems, yet evidence on how the quality of faith-based primary care compares to that of public providers remains limited. Using healthcare worker observations, patient exit interviews, and patient follow-up data from Malawi, we compare consul-tation duration, clinical content, and patient-reported outcomes across faith-based and government facilities. Ordinary least squares estimates controlling for facility-, provider-, and shift-level characteristics, as well as patient health conditions, indicate that FBPs conduct significantly longer consultations, by around 1.9 minutes (75% of the sample mean), and perform a greater number of key clinical processes, including physical examinations and diagnostic tests. Patient-reported data corroborate these findings. Patients attending FBPs report receiving more tests and examinations and, at follow-up, are more likely to state that their treatment is working. These findings provide new evidence that publicly supported FBPs de-liver higher-quality primary care on both process measures and patient-reported outcomes, underscoring the importance of accounting for provider ownership when examining variation in access to quality primary care in Sub-Saharan Africa.

AimsStroke prevention in patients with atrial fibrillation (AF) requires both estimation of risk and the initiation of anticoagulation treatment where indicated. Rapid access atrial fibrillation (RAAF) clinics are an accepted model of multidisciplinary care to reduce time at risk of stroke, but clinical outcomes and cost-effectiveness of them are uncertain. This study aimed to perform a cost-effectiveness evaluation of a RAAF clinic within a large regional health service in Australia. MethodsWe developed a microsimulation model using a cohort of 274 individuals referred to the RAAF clinic between 2022-2023. Clinic data was used to determine risk of stroke, major bleeding, and death from the GARFIELD equation. A comparator was designed by duplicating the cohort and changing the time from referral to consultation to a general cardiology clinic within the same health service (i.e. standard of care). The model ran in daily cycles over a two-year time horizon, with individuals replicated 1,000 times from an initial cohort of 274. The outcomes were strokes, bleeding events, quality-adjusted life years (QALY) and healthcare costs for the RAAF compared to standard of care, which were used to determine incremental cost-effectiveness ratios (ICER), with 5% annual discounting ResultsThe RAAF clinic participants experienced fewer strokes (5,198 vs 5,303), bleeding events (5,369 vs 5,491) and deaths (14,158 vs 14,413). There were marginal increases in QALYs gained (1.67 vs. 1.66 QALY/person), and cost savings of $74 per person ($14,187 vs $14,261), resulting in a dominant ICER. The ICER remained dominant across one-way and probabilistic sensitivity analyses. ConclusionRAAF clinics are likely to prevent strokes, bleeding, and are cost-saving and could lead to returns on investment. Adoption of this model of care by policy makers can ensure the delivery of safe, effective and cost-saving care that reduces stroke, bleeding, and death in people with atrial fibrillation.

BackgroundHealthcare fragmentation among adults with multiple chronic conditions (MCC) may drive inefficient care and increased costs, yet little is known about this relationship at the national level. ObjectiveTo examine the association between healthcare utilization fragmentation and total healthcare costs among US adults with multiple chronic conditions, and assess how this relationship varies by insurance type. MethodsCross-sectional analysis of 21,876 adults from the 2020 Medical Expenditure Panel Survey (MEPS). I measured healthcare fragmentation using a composite score based on utilization across multiple provider types and settings. Multiple chronic conditions were defined as [≥]3 diagnosed conditions. I used surveyweighted regression models to examine associations between fragmentation, MCC status, and total healthcare expenditures, controlling for demographics, socioeconomic status, and insurance type. ResultsThe sample represented 256 million US adults, with 44.7% (SE: 0.6%) having multiple chronic conditions. Adults with MCC had significantly higher healthcare costs than those without MCC (mean: $13,847 vs. $2,145, respectively). Healthcare fragmentation was associated with dramatic cost increases: expenditures ranged from $909 for no fragmentation to $34,956 for high fragmentation. In adjusted models, MCC was associated with a 167% increase in healthcare costs, while each unit increase in fragmentation score was associated with a 784% cost increase. High fragmentation affected 57.9% of the adult population. ConclusionsHealthcare fragmentation is strongly associated with substantially higher costs, particularly among adults with multiple chronic conditions. These findings suggest that care coordination interventions could yield significant cost savings while potentially improving quality of care.

IntroductionIn the Netherlands, referral rates from primary to secondary care are rising due to an ageing population and complex healthcare needs, a challenge compounded by an on-going decline in the number of trained healthcare professionals. In this context, triage has shown promise in optimizing secondary care consultations. This hospital-wide study aimed to assess to what extent triaging non-emergent primary care referrals prevents outpatient consultations, as well as experiences of triage implementation by medical specialists and general practitioners (GP). MethodsA mixed-methods study was conducted using routine care data from electronic health records (EHR) and semi-structured interviews. Referrals to 15 departments between August 2019 and July 2021 were included, with a six-month follow-up period. Referrals were assessed regarding the expected added value of secondary outpatient consultation and correctly chosen specialty. To gain insight into professionals experiences, interviews were conducted with GPs and with medical specialists from each participating department. ResultsA total of 109,953 primary care referrals were registered by participating departments. Of these, 4.262 (3.9%) were directed back to primary care, with redirection varying across departments (0% to 17.1%). Of the redirected referrals with six-months of follow-up, 274 of 3461 patients (7.9%) were re-referred for the same care need within this period. Qualitative findings showed overall positive experiences among medical specialists, with major time investment as the most important barrier to triage. GPs expressed more mixed feelings, with reported barriers including a sense of undermining of autonomy and lack of collaboration, although guidance and advice from specialists was much appreciated. ConclusionThis study showed that a hospital-wide triage strategy can be effective in reducing outpatient consultations, with redirected referrals supported by advice and/or treatment guidance for the referring GP. Qualitative insights suggested that safeguarding mutual respect and cooperation between specialists and GPs needs to be addressed during the implementation of a triage system.

The National i-THRIVE Programme seeks to evaluate the impact of the NHS England-funded whole system transformation on child and adolescent mental health services (CAMHS). This article reports on the design for a model of implementation that has been applied in CAMHS across over 70 areas in England using the THRIVE needs-based principles of care. The implementation protocol in which this model, i-THRIVE (implementing-THRIVE), will be used to evaluate the effectiveness of the THRIVE intervention is reported, together with the evaluation protocol for the process of implementation. To evaluate the effectiveness of i-THRIVE to improve care for children and young peoples mental health, a case-control design will be conducted. N = 10 CAMHS sites that adopt the i-THRIVE model from the start of the NHS England-funded CAMHS transformation will be compared to N = 10 comparator sites that choose to use different transformation approaches within the same timeframe. Sites will be matched on population size, urbanicity, funding, level of deprivation and expected prevalence of mental health care needs. To evaluate the process of implementation, a mixed-methods approach will be conducted to explore the moderating effects of context, fidelity, dose, pathway structure and reach on clinical and service level outcomes. This study addresses a unique opportunity to inform the ongoing national transformation of CAMHS with evidence about a popular new model for delivering children and young peoples mental health care, as well as a new implementation approach to support whole system transformation. If the outcomes reflect benefit from i-THRIVE, this study has the potential to guide significant improvements in CAMHS by providing a more integrated, needs-led service model that increases access and involvement of patients with services and in the care they receive.

Previous work has shown that primary healthcare facilities can benefit from both in-kind support (e.g., medication shipments) as well as increased cash-on-hand to spend to address service readiness gaps. However, there is limited evidence on how facility managers choose to spend available cash or how their decisions to manage their facility budgets are affected by in-kind support. Economic theory suggests that the optimal allocation of cash resources would depend on the context and constraints to how it can be spent, and expenditures would in turn affect the availability of supplies and medications. We test this theory using regression analysis on data from the Nigeria Service Delivery Indicators for Health (SDI), a health facility survey from twelve states in 2013 that included both hospitals and primary healthcare centers (PHCs). We find that facilities with financial resources available to them have higher availability of essential medicines, especially if the facility had earmarked some cash for medication expenditures. However, earmarking for other expenditure categories did not have the same effect on medication availability, which indicates that budgeting processes are an important factor in ensuring medication availability. We find that cash support had large effect (p < 0.001) on availability and that in-kind donations had a negative effect on the probability of expenditure of medications. Additionally, we find the difference between hospitals and PHCs is due to their financial situation (variables become insignificant once support variables were in regressions). Regression analyses also showed that facilities that received in-kind medications had higher availability, but this only had a significant effect in facilities that did not have cash available to spend on medications, implying that facilities are able to address their own supply needs when they have resources available to them. Thus, in-kind supplies should be targeted to facilities that cannot otherwise procure them. Overall, facilities appear to be making effective trade-offs in the context of limited resources and they should receive both cash and support for appropriate budgeting and procurement practices.

PURPOSEOral anticancer agents (OAAs) have transformed cancer treatment by allowing home-based therapy, but adherence remains suboptimal in real-world practice. Guided by Social Cognitive Theory (SCT), this study examined behavioral, cognitive, and socioenvironmental determinants of OAA adherence. PATIENTS and METHODSWe conducted 36 semi-structured interviews with adult cancer patients receiving OAA monotherapy at an academic medical center, a large urban facility, and a rural facility. Interviews were analyzed using a critical realist approach to thematic analysis, deductively guided by SCT. Themes were organized according to the World Health Organizations (WHO) dimensions of adherence. RESULTSFive interrelated themes shaped adherence across WHO dimensions: "[I feel] very confident...Im staying positive about it": Knowledge, Skills, and Self-Efficacy; "Theyll stop me from speaking": Communication and Trust with Providers; "Were at Their Mercy": Logistical Factors in Prescription Refills and Shipment; "Who can afford that?": Distress Related to High Costs and Insurance Coverage Challenges; and "My wife...knows sometimes I forget": Family and Social Support in OAAs Adherence. These findings reflected SCT constructs including self-efficacy, behavioral capability, reinforcement, observational learning, and reciprocal determinism, highlighting the dynamic interactions among personal, social, and health system factors in adherence behavior. CONCLUSIONOAA adherence is shaped by multilevel determinants that extend beyond individual barriers to include provider communication, system logistics, financial burden, and social support. Interventions to improve adherence should be theory-informed, multidisciplinary, and patient-centered, addressing behavioral, relational, and structural influences simultaneously.

The Thanzi La Mawa (TLM) study aims to enhance understanding of healthcare delivery and resource allocation in Malawi by capturing real-world data across a range of health facilities. To inform the Thanzi La Onse (TLO) model, which is the first comprehensive health system model developed for any country, this study uses a cross-sectional, mixed-methods approach to collect data on healthcare worker productivity, patient experiences, facility resources, and care quality. The TLM dataset includes information from 29 health facilities sampled across Malawi, covering facility audits, patient exit interviews, follow-ups, time and motion studies, and healthcare worker interviews, conducted from January to May 2024. Through these data collection tools, the TLM study gathers insights into critical areas such as time allocation of health workers, healthcare resource availability, patient satisfaction, and overall service quality. This data is crucial for enhancing the TLO models capacity to answer complex policy questions related to health resource allocation in Malawi. The study also offers a structured framework that other countries in East, Central, and Southern Africa can adopt to improve their healthcare systems. By documenting methods and protocols, this paper provides valuable guidance for researchers and policymakers interested in healthcare system evaluation and improvement. Given the formal adoption of the TLO model in Malawi, the TLM dataset serves as a foundation for ongoing analyses into quality of care, healthcare workforce efficiency, and patient outcomes. This study seeks to support informed decision-making and future implementation of comprehensive healthcare system models in similar settings.

Primary healthcare (PHC) managers are central to the functioning of South Africas healthcare system, yet many assume leadership roles without formal management training. To address this gap, the Aurum Institute developed the Management Development Programme (MDP), a structured leadership and management training intervention aimed at strengthening PHC management competencies. This study evaluated the impact of the MDP on leadership practices, organisational readiness for change, and workplace stress among PHC managers in the Western Cape Province. A non-randomised matched cluster trial was conducted across 20 PHC facilities. Intervention facilities were purposively selected based on participation in the MDP, while matched control facilities were randomly selected. Data were collected using structured and semi-structured surveys administered to facility managers and clinic staff. Leadership competency was assessed using the Leadership Practices Inventory (LPI), which measures five dimensions of exemplary leadership: Model the Way, Inspire a Shared Vision, Challenge the Process, Enable Others to Act, and Encourage the Heart. Organisational readiness for change was measured using Kotters 8-Step Framework, while workplace stress was assessed using a 13-item version of the Brief Job Stress Questionnaire focusing on Job Meaning, Environmental Quality, Autonomy, and Control. Intervention effects were estimated using generalised linear models adjusted for manager age, years in role, matched-pair fixed effects, and cluster-robust standard errors. Outcomes were reported as adjusted risk differences with 95% confidence intervals and two-sided p-values. A total of 20 facility managers (median age 51 years; IQR 42-55; 90% female) and 105 clinic staff members (median age 42 years; IQR 35-50) participated in the study. Managers in both intervention and control facilities reported consistently high self-rated leadership competency scores across all LPI domains, with no statistically significant differences between groups. Similarly, clinic staff rated managers highly across the standard LPI domains, and no significant differences were observed between intervention and control facilities. Despite the absence of significant differences in overall leadership competency scores, staff in intervention facilities reported significantly stronger relational and communication practices among managers compared with staff in control facilities (72.7% vs. 64.0%; adjusted risk difference 22.0%, 95% CI 6.1-37.8; p=.007). After adjustment for age and tenure imbalances, intervention facilities also demonstrated significantly higher scores for institutionalised capability and learning culture (adjusted risk difference 21.3%, 95% CI 0.6-42.0; p=.043). Managers who participated in the MDP further reported stronger perceptions of district support, including improved internal leadership and cultural readiness (adjusted risk difference 22.1%, 95% CI 14.0-30.3; p<.001) and greater district leadership and resource availability (adjusted risk difference 28.1%, 95% CI 15.6-40.6; p<.001). No statistically significant differences were observed in workplace stress across any domain. Although the MDP did not produce measurable short-term improvements in managers self-rated leadership competencies or standard LPI domains as assessed by staff, it was associated with important gains in relational leadership practices, organisational readiness for change, and perceived district support. These findings suggest that structured management training programmes may strengthen critical organisational and interpersonal foundations necessary for sustained performance improvement within PHC settings.

BackgroundLong queues and overcrowding are common in many of South Africas public healthcare facilities and may negatively impact on the quality of care provided. In HIV-related services, this problem may also affect retention. Healthcare facilities that rely on a system of patient appointments scheduled by day, and not by time, may exacerbate these issues. This study aims to improve retention and care by understanding the challenges and advantages related to the current system of booking appointments and assessing the potential for alternative systems. MethodsThe study was conducted in Johannesburg, South Africa at an outpatient HIV treatment clinic set within a large, urban secondary-level teaching hospital. The study is cross-sectional and includes structured interviews with providers and patients. Medical records are linked with patient interviews and observations to determine actual waiting times. Results245 patients and 6 providers were interviewed. Of the patients interviewed, 64% were female, and 96% were Black African. Nearly a fifth of patients (19%) lost an average of USD 32 in income when attending their appointment. The most common reason for missing an appointment was that they could not be absent from work (40%), but despite this most respondents (65%) do not believe they face any challenges with the current system of booking appointments. Being able to arrive at a time convenient for them was considered a benefit by many (49%), but some (29%) recognized that this may result in overcrowding. The majority of respondents were in favor of appointments offered as a block of time in the morning or afternoon (88%) as well as appointments after work hours (85%). In comparison only just over half (58%) were in favor of booking appointments at a specific time. Most respondents (79%) believe the largest benefit to morning/afternoon block appointments would be the ability to show up at their own convenience during the block of time. ConclusionsPatients value convenience highly. This may be explained by the need to be flexible around work schedules and transport options. It might be worth exploring a booking system in which patients are given a morning or afternoon appointment rather than a day. This may improve the distribution of patients throughout the day and as a result retention and care in a high-prevalence HIV setting.

BackgroundThe PROMISE study was launched in 2018 to assess revisions to an HIV care coordination program (CCP) designed to address gaps in care and treatment engagement among people living with HIV in New York City (NYC). We report on the heterogeneity of provider preferences regarding a revised CCP elicited from a discrete choice experiment (DCE). MethodsFrom January to March 2020, 152 CCP providers in NYC completed a DCE with 4 program attributes: 1) help with adherence to antiretroviral therapy, 2) help with primary care appointments, 3) help with issues other than primary care, and 4) program visit location. Each attribute had 3-4 levels. Latent class analysis (LCA) was used to detect subgroups with differing attribute importance and part-worth utility patterns. Choice simulation was used to estimate providers endorsement of eight hypothetical CCPs. ResultsLCA identified three subgroups. The two larger subgroups (n = 133) endorsed more intensive attribute levels, particularly clients receiving directly observed therapy, and home visits. The remaining smaller subgroup (n = 19) endorsed clients receiving medication reminders and meeting with clients at the program. Simulation showed that intensive medical case management programs had the highest degree of endorsement (62%). ConclusionWhile our results indicate high endorsement among providers for intensive CCP features, overall, they also suggest the need for flexible service delivery options to meet the needs of the clients that these programs serve. Additional information sharing across and within agencies may be warranted to improve the fidelity with which the CCP is implemented.

BackgroundEmotional difficulties post-stroke are common, particularly among people from minoritised ethnic communities or with aphasia, an acquired communication disorder. However, there is a shortage of supportive evidence-based interventions, and of clinical psychologists to deliver them at scale. Wellbeing After Stroke-2 (WAterS-2) is a novel, online, group psychotherapy intervention based on Acceptance and Commitment Therapy. It was designed to support post-stroke psychological adjustment, delivered by a trained non-psychologist workforce to increase potential reach. To guide equitable implementation of such interventions into routine stroke care, this study explored barriers and facilitators from the perspectives of key stakeholders: healthcare commissioners, managers, and frontline clinicians. MethodsQualitative, semi-structured, individual interviews were conducted online with purposively recruited healthcare professionals involved in commissioning, managing, or delivering stroke care in England. The qualitative interview schedule was informed by both the Consolidated Framework for Implementation Research (CFIR) and Normalisation Process Theory (NPT), while the subsequent thematic template analysis was primarily guided by CFIR to explore contextual factors and practical strategies for equitable implementation. ResultsFourteen interviews were conducted, with commissioning managers (n = 8), service managers (n = 4), and clinicians (n = 2). Analyses suggested three themes around the barriers and facilitators likely to influence equitable implementation: (1) Quality of Care vs. Quality of Cash Flow - highlighting a tension between tailoring for inclusion and demonstrating clinical- and cost-effectiveness; (2) Time & Leadership - highlighting a need for leadership to prioritise time investment in equity efforts; (3) Postcode Lottery - highlighting existing variation in local infrastructure, with third-sector partnerships suggested as key enablers. ConclusionEquitable implementation of online psychological support requires balancing the diverse needs of stroke survivors and the constraints of a publicly funded healthcare system. Recommended actions to enable equity provide useful insights for the development, implementation and commissioning of online mental health interventions for stroke survivors. Strategies such as embedding interventions within existing workflows, securing leadership support, and forming partnerships with community organisations may help translate online support like WAterS-2 into routine care.

A key feature of public sector employment in many countries is rigid civil service rules that effectively limit manager autonomy over hiring, firing, promotion, and compensation decisions. We study the effect of these rules by comparing the quality of healthcare provided by physicians employed as civil servants with physicians hired in the same facilities on fixed-term contracts that give managers more autonomy over personnel decisions. Using data from interactions with unannounced standardized patients, we find that fixed-term contracts motivate greater diagnostic effort without increasing unnecessary treatments. Lower effort among civil servants appears due to both weaker career and wage incentives.

AbstractO_ST_ABSObjectivesC_ST_ABSCompare the average cost of an emergency department (ED) visit between three ED care models, namely management by an emergency physician (EP) alone (usual care), management by a primary contact physiotherapist (PT) and an EP (intervention), and management by a PT alone (sensitivity analysis). MethodsCost study (Canadian Public Payer perspective) based on data collected during a pragmatic randomized clinical trial (2018-2019) conducted in an urban Canadian academic ED (CHUL, Quebec City, Canada; n=78, 18-80 years old). Costs incurred for the management of persons presenting to the ED for a minor musculoskeletal disorder (MSKD) were calculated using Time-Driven Activity-Based Costing, in which time invested with a patient determines care costs. The main outcome measure was the average cost of an ED visit. Generalized linear models with Gamma distributions and log links were used to assess whether there were significant differences in average costs between the care models. ResultsMean ED visit cost was $267.08 (2019 $CAD, 95%CI: $212.75, $346.40) for PT and EP management, compared with $245.14 for EP management ($169.46, $336.72), resulting in a non- significant absolute difference of 21.94 CAD/patient ($-87.33, $132.63) between models (p=.60). Sensitivity analyses showed that the average cost of ED management by a PT was $194.38 ($161.50, $234.34), representing a non-significant average saving of 50.76 CAD/patient ($- 156.91, $37.54) compared to EP management. ConclusionThis study is a first step towards a better understanding of the costs incurred by the Canadian Public Payer for the management of persons presenting with MSKDs in the ED. Primary contact physiotherapists have the potential to complement care of MSKD ED patients without increasing healthcare costs.

BackgroundThe need to better manage frequent attenders or high-impact users (HIUs) in hospital emergency departments (EDs) is widely recognised. These patients often have complex medical needs and are also frequent users of other health and care services. The West of England Academic Health Science Network launched its Supporting High impAct useRs in Emergency Departments (SHarED) quality improvement programme to spread a local HIU intervention across six other EDs in five Trusts. AimSHarED aimed to reduce ED attendance and hospital admissions by 20% for enrolled HIUs. To evaluate the implementation of SHarED, we sought to learn about the experience of staff with HIU roles and their ED colleagues, and assess the impact on HIU attendance and admissions. MethodsWe analysed a range of data including semi-structured interviews with 10 HIU staff; ED staff training; an ED staff experience survey; and ED attendances and hospital admissions for 148 HIUs enrolled in SHarED. ResultsStaff with HIU roles were unanimously positive about the benefits of SHarED for both staff and patients. SHarED contributed to supporting ED staff with patient-centred recommendations and provided the basis for more integrated case management across the health and care system. 55% of ED staff received training. There were improvements in staff views relating to confidence, support, training, and HIUs receiving more appropriate care. The mean monthly ED attendance per HIU reduced over time. Follow-up data for 86% (127/148) of cases showed a mean monthly ED attendances per HIU reduced by 33%, from 2.1 to 1.4, between the six months pre- and post-enrolment (p<0.001). ConclusionSHarED illustrates the considerable potential for a quality improvement programme to promote more integrated case management by specialist teams across the health and care system for particularly vulnerable individuals and improve working arrangements for hard-pressed staff. What is already known on this topicFrequent attendance in hospital emergency departments is a worldwide problem that, despite the national recognition of the rationale for better management of high-impact users, has relied on the local efforts of clinicians to change working practices. What this study addsThe Supporting High impAct useRs in Emergency Departments (SHarED) quality improvement programme was successful in spreading a model of high-impact user management based on the identification, proactive management, monitoring and review of these patients, with clear benefits to emergency department staff, and potential benefits to patients and resource use. How this study might affect research, practice or policySHarED illustrates the considerable potential for a quality improvement programme to promote more integrated case management by specialist teams across the health and care system for particularly vulnerable individuals and improve working arrangements for hard-pressed staff.

BackgroundOn June 6, 2011 the Emergency Department (ED) at Southlake Regional Health Center, a very high-volume ED, initiated a comprehensive redesign project to improve patient waiting times. The primary initial goal of the project was to reduce Time to Physicians Initial Assessment (TPIA) - one of the Key Performance Indicators (KPIs) tracked by the Ontario Ministry of Health and Long-Term Care. The objective was to achieve a significant improvement in TPIA without sacrificing performance on any other important KPIs such as Length of Stay (LOS), Left Without Being Seen (LWBS), or time to admission (T2A). The effect on TPIA was immediate and dramatic: the 90-th percentile TPIA declining from 4 hrs to under 2.5 hrs, with further improvements seen over time. The patient in-flows also increased; anecdotally this increase was directly related to shorter wait time. However, like any other large-scale and on-going system redesign project, the impacts are not limited to the listed KPIs, but are multi-dimensional, affecting patient inflows, flows within the ED, workloads, staffing levels, etc. Thus, teasing out the impact of system redesign requires from other concurrent factors (population changes, staffing changes, etc.) requires a comprehensive system assessment. The available data exhibits auto-correlations, heteroscedasticity, and interdependence among variables, rendering simple statistical analysis of individual KPIs inapplicable. We develop a novel methodology and conduct counterfactual analysis demonstrating that the decrease in TPIA, as well as new patient inflows can indeed be attributed to the ED redesign. This suggests that a similar system redesign should be considered by other EDs looking to improve wait times. ObjectivesTo (1) statistically estimate the impacts of the redesign project on various performance measures over time, (2) examine whether the projects initial goal of improvement in TPIA without compromising other service performance measures was achieved, and (3) study whether the project impacted patient inflows. MethodsWe (1) estimate simultaneous equations models to quantify interdependent and timevarying relations among variables, (2) conduct an iterative counterfactual analysis to estimate the mean-level impacts of the project, and (3) construct 95% confidence intervals for the estimated impacts using the Bootstrap method. ResultsWe study project impacts over 720 days after it was initiated. During this time, the 90th percentile of TPIA has been reduced by nearly 2.5 hours on average (translating into an over 50% improvement), with continuous improvement over the study period. This effect is statistically and operationally significant. The project also improved LOS for non-admitted patients (both acute and non-acute), and did not have statistically significant impact on LOS for admitted patients. There was also a decrease in LWBS, though it was not statistically significant. Thus the project achieved its stated primary goals. We also observed an increase in inflows of both acute and nonacute patients; our analysis confirms that this increase can be attributed to the project, indicating that improvements in TPIA attracted new patients to the ED. All of these effects have persisted over the 720-day post-project period. ConclusionsThe redesign project has significantly reduced TPIA over time while also improving some LOS measures; none of the waiting time KPIs were compromised. The reduction in TPIA also attracted significant volumes of new patients. However, the redesigned process was able to deal with this volume without compromising performance. The redesign project involved a number of major changes in ED operations. We provide an overview of these changes, and while our analysis cannot attribute specific project impacts to specific changes, we believe that implementing similar changes should receive strong consideration by other EDs. Conflicts of interestNone