In 2008, the lack of a robust estimate for the proportion of patients experiencing preventable deaths in English acute hospitals was fuelling debate and hindering progress in tackling the underlying problems associated with serious patient harm. In this thesis a narrative literature review and a study of harm measures in a single acute hospital are used to guide the choice of method for a study to determine the proportion of preventable hospital deaths. A subsequent retrospective case record review (RCRR) of 1000 randomly sampled deaths from 10 English acute hospitals found the proportion of preventable deaths to be 5.2% (95% CI, 3.8% to 6.6%) which would equate to 11,859 (95% CI 8712 to 14 983) preventable deaths per year in NHS hospitals in England, 60% of whom had a life expectancy of less than 1 year. The proportion was lower than previous estimates based on US RCRR studies but consistent with a recent Dutch study which reviewed 3,983 hospital deaths. The majority of underlying problems in care were related to clinical monitoring, diagnostic error and drug and fluid problems, and 44% occurred during ward care. Problems were more likely to occur in surgical than medical patients (23.6% vs12.7%). Three-quarters were omissions, rather than commissions, in care and accumulated throughout the hospital episode. While there was a strong positive correlation between proportions of preventable deaths in hospitals and MRSA bacteraemia rates (r=0.73; p<0.02) there were no other significant associations with common measures of safety, including HSMR. Improvements are needed to reduce human error and to provide better quality of care for acutely ill older people to reduce serious harm in acute hospitals. A national mortality review process, based on this study, is to be rolled out across the NHS and will provide one mechanism for monitoring progress.

No description available.

In industrialized countries there has been a long debate about the extent of market failure in health care. Recently similar concerns have arisen in developing countries as international organizations have advocated a greater role for the private sector. In many developing countries the private health care sector is already substantial, yet limited information is available about the behaviour of private providers. Empirical evidence is essential to the formulation of policies about and regulation of the private sector. This study explores the nature of hospital competition in Bangkok and in particular the impact which (i) problems of asymmetric information (ii) product differentiation and (iii) consumer behaviour have upon hospital competition. The nature of hospital competition is analysed directly through examining the impact of market concentration on prices, profitability, intensity and quality of care provided, and indirectly through a consideration of the underlying market conditions and institutions and their impact on competition. Direct evidence is sought through the analysis of a hospital database covering approximately forty hospitals in the Greater Bangkok area. The indirect evidence is based on a survey of consumer knowledge and behaviour in the Bangkok health care market, supported by interviews and document review. A substantial degree of both horizontal and vertical product differentiation is observed amongst hospitals in Bangkok. Consumers are relatively well-informed about differences between hospitals, willing to seek further information and quite sophisticated in their decision-making, however only limited price sensitivity is apparent. Non-price competition is dominant; hospitals facing higher competition have higher profitability and higher prices. Some evidence of both quality competition and supplier induced demand is found, but the study is inconclusive as to the extent of these. The findings support concerns in Thailand about the problems associated with a poorly regulated private health care sector and highlight the difficulties in regulating a very complex market such as that for hospital care.

Introduction: Despite the growing emphasis on the collection, monitoring and reporting of outcomes of surgical care within the UK, few data exist for such purposes. Equally, few data are available on disease occurrence and surgical practice in England. In this thesis, the hypothesis that Hospital Episode Statistics (HES) data can be used for such purposes is tested. Methods: The objectives of this thesis were twofold. Firstly, to review the literature to establish to what extent lIES data has been used to study incidence, surgical treatments and their outcomes. Secondly, to evaluate - using a number of individual lIES-derived case studies, to what extent the lIES database can be utilised to answer clinical questions concerning incidence, practice and outcome of urological surgery. Strengths and weaknesses of the lIES database were subsequently sought on which to generate recommendations concerning the future clinical use of the database. Results: The review highlighted the completeness of the database identifying very low underascertainment when compared to local audit data although did identify that use of Finished Consultant Episodes (FCE'S) resulted in over-estimation of disease incidence. lIES-derived case studies suggested, first, the incidence of hypospadias was considerably higher than previously reported and furthermore, did appear to be on the increase. Second, boys continue to undergo clinically inappropriate foreskin surgery. Third, the shift away from surgery for men with symptomatic BPlI has not resulted in more men experiencing an episode of acute urinary retention. Fourth, high-volume cancer centres appear to achieve improved outcomes following cystectomy by reducing the risk of "failure-to-rescue" following an adverse event. Recommendations on the future clinical use of HES data drawn from the HES-derived case studies were first, if incidence is to be calculated using HES data, there must be no or minimal ambiguity regarding diagnostic or procedural coding. Second, a number of diagnostic and procedural codes can be "operationalised" to define an event provided coding practice is not identified in advance. Third, the incidence of a condition can be identified using HES data provided all patients or at least the majority of patients undergo hospital treatment for that condition. Fourth, for HES data to comment on clinical appropriateness of treatment, the prevalence of the condition requiring treatment must be known. Fifth, if HES data is to be used to analyse trends in disease incidence over time, there must be no changes in coding practice over the study period. Sixth, HES data should not be used in isolation to report long-term oncological outcomes. Seventh, HES data is suitable to investigate the determinants of short-term surgical outcome such as mortality. Conclusion: Evaluation of the use of HES data to answer specific questions concerning the incidence, practice and outcome of urological surgery suggests HES is a useful source of data provided caveats concerning the strengths and weaknesses of the database are considered at the time of data analysis.

Background Communication regarding medicines at hospital discharge via discharge summaries is notoriously poor and negatively impacts on patient care. With the process being dependant on the quality of patient records during admission, junior doctors who write them and General Practitioners (GPs) who receive them, the objectives of this thesis were, with respect to discharge summaries, to:-  assess their timeliness, accuracy and quality  describe GP preferences  explore experiences of junior doctors regarding their preparation. Methods Discharge summaries produced from one district general hospital were audited, as was the impact of changing the format of inpatient drug charts. A combination of observation, think-aloud and ethnographic interviews were conducted to investigate experiences of junior hospital doctors preparing summaries. A survey of GPs and junior doctors was undertaken to compare attitudes towards the discharge process. A pilot Discrete Choice Experiment (DCE) was developed and undertaken with GPs to determine their preferences with respect to the format, quality and timing of discharge summaries. Results A large proportion of discharge summaries were found to be inaccurate, however this was reduced when checked by a pharmacist. Key barriers to summary preparation identified were lack of time, training and knowledge of the patient. GPs perceived medicine changes on discharge summaries to be more important than did junior doctors. The DCE found that GPs were willing to trade timeliness of discharge summaries with accuracy. Discussion and conclusions The error rate within discharge summaries highlights the importance of a pharmacy accuracy check. The national requirement to deliver discharge summaries within 24 hours of discharge results in the pharmacist being bypassed and places additional pressure on junior doctors to prepare them in a timely manner, which might provide explanation for poor quality. Interestingly, GPs were willing to forego receipt of discharge summaries within 24 hours in preference for a reduced error rate. Keywords: patient discharge, discharge summary, patient transfer, interdisciplinary communication, medication errors.

Background: It is important that when older adults are admitted to hospital wards, they feel valued, and receive compassionate and respectful care. There is an impetus on nurses to explore their practice and investigate and appraise ways of working that will lead them beyond foundational care delivery towards informed person-centred practice. Aim: This thesis aimed to investigate and transform cultures to enhance nursing care of older adults in hospital settings. Design and methods: The thesis presents a selection of 3 studies (generating 5 papers) from the author's published works for enhancing nursing care of older adults. The designs included appreciative inquiry, secondary qualitative data analysis, participatory action research, systematic practice development and narrative enquiry. At the core of each design is the premise, that context and human behaviour cannot be interpreted in isolation. That linkage grounds the studies in social critical theory and resonates through the approaches and processes selected for methods and analysis of the data. The integrated Promoting Action on Research Implementation framework (i-PARIHS) was used to focus indepth discussion on contexts, innovation, recipients and facilitation for knowledge uptake into practice for transforming cultures of care. Summary of Findings: The key findings are 1) the importance of facilitation for generating a shared learning culture in hospital wards for the exploration and investigation of practice, 2) the exposure of vulnerability in the care experience of older adults, and 3) the conveyance of a disempowered space shared by older adults and their nurses. The thesis demonstrates that a range of research designs rooted in critical social theory are appropriate for enabling nurses to explore, investigate and transform cultures to enhance ways of working for nursing older adults in hospital settings. Implications of the work: Implications have been drawn for further refinement of the iPARIHS framework, for future research, for nursing practice and nurse education. A recommendation is the embracement of 'co-innovators' in knowledge uptake into practice research. The implication for nursing practice is the contribution of transformational leadership and facilitative processes for enabling nurses and interdisciplinary teams to collaboratively explore issues in practice and make ready workplace culture for change. 'Hearing all voices', the epistemological stance of the thesis and 'discourse is action', a tenet of critical social theory have implications for the approaches that would generate a shared learning culture in the pre-registration nursing curriculum.

No description available.

The primary aim of the thesis is to understand how to strengthen primary care in China, by looking at the effectiveness and functioning of a gatekeeping pilot, and more broadly at the history of the balance between hospitals and primary care providers. A secondary aim is to explore how multiple methods can be used to study a complex system-related issue. The thesis developed comprehensive metrics for structural and functional balance between primary and hospital care (1949-2013); developed a dynamic path dependence analytical framework to study the coevolution of the two sectors (1835-2013); used a difference-in-differences analysis to identify the impact of a gatekeeping pilot; and developed a qualitative systems analysis to understand the functioning of the pilot. The quantitative analysis suggested more patients did visit primary care facilities (increased by 38.7%) due to the pilot, but without obvious extra-spending. Evidence from the qualitative study suggested this seemed to be caused by patients visiting for referrals. The intended effects of gatekeeping in changing patients’ utilization pattern of care were made unattainable mainly by the existing weak conditions of primary care, feedback loops that further weakened primary care development regarding service capacity, human resources, and patient trust, as well as unintended consequences of other related policies. The dynamics between hospitals and primary care providers in the pilot were the contemporary manifestation of a long-term hospital-centric structure, where primary care providers were the de-professionalized antithesis of hospitals and relatively weakly institutionalized. The institutional complex was path-dependent and has gone through three cycles since 1835. The thesis has demonstrated the feasibility and value of using multiple analytical theories and research methods to address a complex health system issue. The findings of the study suggest the importance of building a strong primary care profession and the value of a political coalition for primary care strengthening.

Aim: This thesis aims to explore and investigate the level and process of adoption of Antimicrobial Stewardship Programmes (ASPs) and factors influencing their implementation in Saudi Ministry of Health (MOH) hospitals. The findings of this study will provide hospitals and policy makers with evidence-based recommendations on how barriers to ASPs adoption can be overcome, which will ultimately improve antimicrobial use and reduce antimicrobial resistance (AMR). Method: A mixed method approach was carried out using both qualitative and quantitative research methods. Semi-structured interviews were conducted with healthcare professionals in three Saudi hospitals to explore the enablers and barriers to their adoption of ASPs. A survey was then developed based on these findings to investigate the level of hospitals’ adoption of ASPs and factors influencing their implementation at a national level. Further, a case study using in-depth interviews was utilised to understand the process of ASP adoption in a Saudi hospital, and how adoption challenges were addressed. Finally, a self-administered questionnaire was used to examine patients’ knowledge and perceptions of antimicrobial use and resistance, and to evaluate the institutional role of patient education on antimicrobial use in two Saudi hospitals. The overall methodology of the research is summarised in Figure I. Results: Despite the introduction of a national ASP strategy, adoption of ASPs in Saudi MOH hospitals remains low. Organisational barriers such as the lack of senior management support, lack of supportive IT infrastructure and the shortage of ASP team members hinder hospitals’ efforts to adopt ASPs. Further barriers relate to the lack of formal enforcement by MOH and the physicians fears of patients' complications and clinical liability. Patients admitted to Saudi hospitals lack knowledge and perceptions of AMR, and the adoption of ASPs may improve hospitals’ role in patients' education. Conclusions: Despite the established benefits of ASPs, their adoption in Saudi MOH hospitals remains low. Urgent action is needed to address the strategies priorities associated with AMR, including access to antimicrobials, antimicrobial stewardship and education and research. Policy makers are urged to consider making ASPs adoption in hospitals a regulatory requirement supported by national guidelines and surveillance programmes. It is essential to increase the provision of ID and infection control residency and training programmes to meet the extreme shortage of ID physicians, pharmacists, microbiologists and infection control practitioners. Higher education institutions and teaching hospitals are required to introduce antimicrobial prescribing and stewardship competencies into undergraduate Medical, Pharmacy, Dental, Nursing and Veterinary curriculum, as well as introduction of AMR topics in order to increase knowledge and awareness of ASPs and AMR. Collaboration between ASPs adopting and non-adopting hospitals is essential to share implementation experience, strategies and solutions to overcome barriers. Healthcare specialised associations are needed to be part of AMR conversation and guide healthcare professionals’ training and accreditation. Multiple stakeholders should be actively part of the conversations around tacking AMR. Primary care, secondary care, community pharmacies and policy makers should strive to create a shared culture of responsibility among all healthcare partners to improve antimicrobial therapy and reduce risks of AMR

This thesis considers applications of machine learning techniques in hospital emergency readmission and comorbidity risk problems, using healthcare administrative data. The aim is to introduce generic and robust solution approaches that can be applied to different healthcare settings. Existing solution methods and techniques of predictive risk modelling of hospital emergency readmission and comorbidity risk modelling are reviewed. Several modelling approaches, including Logistic Regression, Bayes Point Machine, Random Forest and Deep Neural Network are considered. Firstly, a framework is proposed for pre-processing hospital administrative data, including data preparation, feature generation and feature selection. Then, the Ensemble Risk Modelling of Hospital Readmission (ERMER) is presented, which is a generative ensemble risk model of hospital readmission model. After that, the Temporal-Comorbidity Adjusted Risk of Emergency Readmission (T-CARER) is presented for identifying very sick comorbid patients. A Random Forest and a Deep Neural Network are used to model risks of temporal comorbidity, operations and complications of patients using the T-CARER. The computational results and benchmarking are presented using real data from Hospital Episode Statistics (HES) with several samples across a ten-year period. The models select features from a large pool of generated features, add temporal dimensions into the models and provide highly accurate and precise models of problems with complex structures. The performances of all the models have been evaluated across different timeframes, sub-populations and samples, as well as previous models.