Background: Pharmacy-related performance measures have gained significant attention in the transition to value-based healthcare. Pharmacy-level quality measures, including those developed by the Pharmacy Quality Alliance, are not yet publicly accessible. However, the publication of report cards for individual pharmacies has been discussed as a way to help direct patients towards high-quality pharmacies. This study aimed to measure the relative strength of patient preferences for community pharmacy attributes, including pharmacy quality. Additionally, this study aimed to identify and describe community pharmacy market segments based on patient preferences for pharmacy attributes. Methods: This study elicited patient preferences for community pharmacy attributes using a discrete choice experiment (DCE) among a sample of 773 adults aged 18 years and older. Six attributes were selected based on published literature, expert opinion, and pilot testing feedback. The attributes included hours of operation, staff friendliness/courtesy, pharmacist communication, pharmacist willingness to establish a personal relationship, overall quality, and a drug-drug interaction specific quality metric. Participants responded to a block of ten random choice tasks assigned by Sawtooth v9.2 and two fixed tasks, including a dominant and a hold-out scenario. The data were analyzed using conditional logit and latent class regression models, and Hierarchical Bayes estimates of individual-level utilities were used to compare preferences across demographic subgroups. Results: Among the 773 respondents who began the survey, 741 (95.9%) completed the DCE and demographic questionnaire. Overall, study participants expressed the strongest preferences for quality-related pharmacy attributes. The attribute importance values (AIVs) were highest for the specific, drug-drug interaction (DDI) quality measure, presented as, “The pharmacy ensured there were no patients who were dispensed two medications that can cause harm when taken together,” (40.3%) and the overall pharmacy quality measure (31.3%). The utility values for 5-star DDI and overall quality ratings were higher among women (83.0 and 103.8, respectively) than men (76.2 and 94.5, respectively), and patients with inadequate health literacy ascribed higher utility to pharmacist efforts to get to know their patients (26.0) than their higher literacy counterparts (16.3). The best model from the latent class analysis contained three classes, coined the Quality Class (67.6% of participants), the Relationship Class (28.3%), and the Convenience Class (4.2%). Conclusions: The participants in this discrete choice experiment exhibited strong preferences for pharmacies with higher quality ratings. This finding may reflect patient expectations of community pharmacists, namely that pharmacists ensure that patients are not harmed by the medications filled at their pharmacies. Latent class analysis revealed underlying heterogeneity in patient preferences for community pharmacy attributes.

People who need a liver transplant must choose a hospital at which the transplant will be performed. The United Network for Organ Sharing (UNOS) allocates organs to patients based on patient characteristics and assumes all hospitals have equal skill. The question for a patient thus becomes, which hospital to choose? This thesis investigates whether the differences in liver transplant survival rates for hospitals are a result of differences in patients and/or differences in hospital-specific criteria. The findings in this thesis show that most of the differences in hospital survival rates are due to patient characteristics, and that, while not conclusive, hospital characteristics may have an impact on survival rates. However, the variable that is most significant to survival rates is the cold ischemic time, or transportation time of the organ. These results suggest that policies to allocate organs nationally are not optimal. / Master of Arts

This thesis is based on 18 months ethnographic fieldwork in and around the National Heath Service (NHS) in Greater Manchester, UK, between 2011 and 2012. The fieldwork focused on practices and experiences of cancer care and the care of other related diseases (e.g. brain tumour, post surgical pain and cancer related mental illnesses) and primarily involved in-depth interview-based case studies with patients, carers and clinicians, as well as participant observation at hospital outpatient clinics and a local cancer centre. Over the past thirty years, the English NHS has been through numerous market- based structural reorganisation programmes broadly aimed at increasing provider competition and patient choice within the health service. At the same time, various new ways of configuring medical knowledge and reforming the ‘traditional clinical interaction’ have grown in influence in NHS care practices. This thesis seeks to record the ways in which new managerial technologies, clinical tools and medical and healthcare rationalities (e.g. risk medicine, patient pathways, diagnostic categories and the logic of patient choice) introduce new ways to experience disease and treatment. Following Das (2015), among others (see Biehl and Moran- Thomas 2009), I do not treat these abstract forms as dominating forces that over-determine experience and practice. But instead, I attend to how broad structures and rationalities become embedded in practices, experiences and biographies of illness and care. In particular, I focus on what is required for care to be accessed (or ‘activated’) in a context permeated by these competing systems of value and meaning.

Syftet med studien var att beskriva hur distriktssköterskan upplever införandet av valfrihets­system i primärvården. Vidare var syftet att beskriva varför distriktssköterskan stannar kvar inom den landstingsdrivna primärvården då nya privata aktörer finns tillgängliga. Studien hade en beskrivande design där tio distriktssköterskor från en stad i Mellansverige blev inter­vjuade. Det insamlade materialet blev transkriberat och analyserat med hjälp av kvalitativ innehållsanalys. Resultatet strukturerades i två innehållsområden. Det första innehållsområdet upplevelse av införandet, redovisades i temat Patienten har fått makt genom att kunna välja, kategorier samt subka­tegorier. I kategorin ekonomiskt tänkande har blivit viktigt be­skrev distriktssköterskorna att det nu blivit viktigt att lista patienter samt att nya administra­tiva rutiner införts. Patienten har blivit kund vilket lett till att distriktssköterskan fått ett nytt förhållningssätt till patienten och blivit mer serviceinriktad. Valfrihet kräver information, patienten behöver information för att vara insatt i reglerna kring valfrihetssystemet då det kan ge konsekvenser för patienter med särskilda behov. Det andra innehållsområdet skäl att stanna, redovisades i kategorier samt subkategorier. Distriktssköterskan beskrev att hon valde att stanna kvar inom den landstings­drivna primärvården då ar­betsplatsen i sig var avgörande genom trivsel och kollegor samt att det inte varit till­räckligt lockande att byta arbetsplats då en anställning i landstinget uppfatta­des som en trygg­het. / The aim of the study was to describe how district nurses experienced the introduction of the system of patient choice in primary care. The aim was also to describe why the district nurse in the public primary care decides to stay when new private actors are available. The study had a descriptive design where ten district nurses from different health centers from a town in Middlesweden were interviewed. The collected material was transcribed and analyzed using qualitative content analysis. The result was structured in two content areas. The first content area experience of the introduction, was presented in the theme Patient had power by beeing able to choose, cat­egories and subcategories. In the category Economic thinking has be­come important the dis­trict nurse described that it is now important to register the patient at the health center and that they now have new administrative procedures in place. The patient has become customer and this leads the district nurse to approach the patient in a new way and become more service-oriented. Choice requires information and the patient needs infor­mation to be familiar with the rules on patient choice system then it can have consequences for patients with special needs. The se­cond content area, reasons to stay, was presented in categories and subcategories. The district nurse decides to remains in the public primary care when the workplace itself is crucial in comfort and colleagues and that it has not been attractive enough to change job when em­ployment in the County Council was perceived as a security.

Thesis (DPhil (Philosophy))--University of Stellenbosch, 2010. / ENGLISH ABSTRACT: This study involves a critically evaluation of evidence-based patient choice as partnership model in clinical decision making. It pays attention to the emergence of the concept of autonomy in modern moral philosophy and in particular to the pivotal contributions of Immanuel Kant and John Stuart Mill in this regard. Against this background, it elaborates on the ethical principle of respect for autonomy, informed consent as paradigm for patient autonomy in clinical decision making, the conflicts that arise between the ethical concepts of autonomy and beneficence, the dominance of paternalism in clinical decision making, the challenges posed to the dominance of paternalism, the resulting emergence of the concept of partnership in clinical decision making and evidence-based patient choice as partnership model in clinical decision making. Moreover, it provides an exposition of the context, nature and practice of evidence-based patient choice and of the four key decision making skills required from health care professionals to involve patients in clinical decision making, namely shared decision making, risk communication, decision analysis, and the use of decision aids. Against this background, it critically evaluates the effectiveness of evidence-based patient choice as partnership model in clinical decision making by judging it in terms of the ethical concept of patient autonomy as reflected in the informed consent elements of competence, disclosure, understanding and voluntariness and indicates that none of the key skills of evidence-based patient choice can be regarded as completely adequate in honouring the principle of respect for autonomy in clinical decision making and that consequently each of these four key skills leave evidence-based patient choice with a challenge that needs to be addressed from another angle in order to establish and maintain the ethical principle of respect for autonomy. In response to these challenges, the study makes three recommendations for the transformation of evidence-based patient choice to a therapeutic alliance health care, namely to review and further develop the philosophical foundations of evidence-based patient choice, to consider the continental philosophical perspectives of Edmund Husserl, Jean-Paul Sartre, Maurice Merleau-Ponty and Jürgen Habermas on the evidence-based patient choice challenges of the separate worlds of doctor and patient, the constitution of meaning in illness and the dangers of abstractions and informational manipulation in health care and to transform the practice of evidence-based patient choice to a therapeutic alliance in health care by individualising the provision of information by embedding it in the human processes of sense making, knowledge creation and decision making through which information is transformed into insight, knowledge and action. / AFRIKAANSE OPSOMMING: Die studie behels 'n kritiese evaluering van evidence-based patient choice as vennootskapsmodel in kliniese besluitneming. Dit verwys na die opkoms van moderne morele filosofie en in die besonder na die deurslaggewende bydraes van Immanuel Kant en John Stuart Mill in hierdie verband. Teen hierdie agtergrond bespreek dit die etiese beginsel van respek vir outonomie, ingeligte toestemming as paradigma vir pasiënt outonomie in kliniese bsluitneming, die moontlike konflikte tussen die etiese konsepte van outonomie en weldadigheid, die dominansie van paternalisme in kliniese besluitneming en die uitdagings wat dit ontlok het, die gevolglike ontstaan van die konsep van vennootskappe in kliniese besluitneming, asook evidence-based patient choice as vennootskapsmodel in kliniese besluitneming. Voorts verskaf die studie 'n uiteensetting van die konteks, wese en praktyk van evidence-based patient choice, asook van die vier sleutelvaardighede wat van medici vereis word ten einde pasiënte in kliniese besluitneming te betrek, naamlik gedeelde besluitneming, die kommunikasie van risikos, die analise van besluitneming en die gebruik van besluitnemingshulpmiddels. Teen hierdie agtergrond onderneem die studie 'n kritiese evaluering van die effektiwiteit van evidence-based patient choice deur dit te meet aan die ingeligte toestemming elemente van kompetensie, blootlegging, verstaan en vrywilligheid en toon aan dat geeneen van hierdie sleutelvaardighede as volledig toereikend in die nastreef van die beginsel van respek vir outonomie in kliniese besluitneming beskou kan word nie en evidence-based patient choice daarom met uitdagings laat wat vanuit 'n ander hoek bearbei moet word ten einde die beginsel in die praktyk te vestig en te onderhou. In reaksie hierop maak die studie drie aanbevelings met die oog op die transformering van evidence-based patient choice na 'n terapeutiese alliansie in gesondheidsorg, naamlik om die filosofiese grondslae van evidence-based patient choice in oënskou te neem en verder te ontwikkel, om oorweging te skenk aan die kontinentaal filosofiese perspektiewe van Edmund Husserl, Jean-Paul Sartre, Maurice Merleau-Ponty en Jürgen Habermas met betrekking tot die evidence-based patient choice uitdagings van die verskillende wêrelde van dokter en pasiënt, die konstituering van betekenis in siekte en die gevare verbonde aan die abstrahering en manipulering van inligting in gesondheidsorg en om op grond hiervan die praktyk van evidence-based patient choice te transformer. Dit sal gedoen word deur die verskaffing van inligting aan pasiënte te individualiseer deur dit in te bed in the menslike prosesse van sinmaking, kennis generering en besluitneming waardeur inligting getransformeer word tot insig, kennis en aksie.

Background: Increased pressure, rising demand and cost constraints have driven a need for radical service re-design in the NHS. To deliver re-design objectives it is necessary to understand how they are perceived by service users and providers. Aim: To investigate the views of patients and health care professionals (HCP) on aspects of health policy and service re-design affecting primary care. Setting: Patients and HCPs from one geographical area in England. Method: Themes from phase one qualitative interviews were explored quantitatively using a questionnaire in phase two and a discrete choice experiment (DCE) in phase three. Factor analysis was used to explore HCP responses in phase two. In phase three the DCE was administered to explore patients‟ relative priorities of a range of attributes. Results: HCPs had concerns that the Quality Outcomes Framework (QOF) detracted from the patient‟s agenda and did not improve health outcomes. GPs felt continuity of care was important Monday through Friday but were not keen on its provision out of hours. Neither did they feel nurses could run chronic disease management clinics without a GP present. Patients felt continuity could be provided by different HCPs for different conditionsPatients stated continuity of care and consultation duration were the most important attributes in a primary care service. However, in the DCE they prioritised both being seen on the day and by a GP over longer appointments. Patient preference to be seen by a GP may reflect the low uptake of non-medical prescribing in the area. Conclusion: Continuity of care, while remarked as being important to both HCPs and patients, appears less important when weighted against other primary care service attributes. HCPs appear to want longer consultations whereas patients saw time as encompassing both the time to wait for an appointment and consultation length. For patients, the quality of the time with a HCP may be more important than its duration, additionally patients appear to want choice but not necessarily to choose.

Objective. Research testing the concept of decision-making styles in specific contexts such as health care–related choices is missing. Therefore, we examine the contextuality of Scott and Bruce’s (1995) General Decision-Making Style Inventory with respect to patient choice situations. Methods. Scott and Bruce’s scale was adapted for use as a patient decision-making style inventory. In total, 388 German patients who underwent elective joint surgery responded to a questionnaire about their provider choice. Confirmatory factor analyses within 2 independent samples assessed factorial structure, reliability, and validity of the scale. Results. The final 4-dimensional, 13-item patient decision-making style inventory showed satisfactory psychometric properties. Data analyses supported reliability and construct validity. Besides the intuitive, dependent, and avoidant style, a new subdimension, called ‘‘comparative’’ decision-making style, emerged that originated from the rational dimension of the general model. Conclusions. This research provides evidence for the contextuality of decision-making style to specific choice situations. Using a limited set of indicators, this report proposes the patient decision-making style inventory as valid and feasible tool to assess patients’ decision propensities.

Le système de santé français repose sur une dichotomie publique-privée. Cette dualité juridique se retrouve dans l’offre de soins proposée aux patients qui disposent du libre choix de se faire hospitaliser aussi bien en établissement de santé public qu’en établissement de santé privé, l’hospitalisation privée devenant prépondérante en France. Pour le patient peu importe la structure d’hospitalisation, puisque les droits des patients étant des droits fondamentaux, pour certains constitutionnellement garantis, ce dernier doit bénéficier des mêmes droits quel que soit le lieu de son hospitalisation. Or les conséquences engendrées par la spécificité « privée » de l’établissement de santé amène à s’interroger sur une éventuelle disparité dans l’application des droits du patient, qui pourraient être à l’origine d’un statut propre au patient hospitalisé en établissement de santé privé. / The French healthcare system relies on a public-private dichotomy. This difference in legal status is reflected in the actual provision of healthcare, as patients have the right to choose their preferred type of hospitalization with private sector hospitalizations now becoming predominant in France. However, patients must be granted the same rights regardless of which type of hospital they have chosen, due to the fact that patients' rights are fundamental rights, and for some of them they are constitutionally guaranteed. The implications of the specific nature of private hospitals raise questions about a potential disparity in the application of patients' rights, which would result in a different status for patients entering private hospitals.