Digital Theses Archive


Tesi etd-10262021-234349

Type of thesis
The role of managerial systems in promoting higher value care: Incorporating the patient voice in public value management
Scientific disciplinary sector
Istituto di Management - MANAGEMENT
relatore Prof.ssa NUTI, SABINA
Membro Prof.ssa VAINIERI, MILENA
Membro Prof. Pier Luigi Lopalco
Membro Prof. BELLE', NICOLA
  • Nessuna parola chiave trovata
Exam session start date
This thesis explores how patient-reported data can be used at different stages in the continuous cycle of value creation from performance information in health systems. <br><br>The topic of value in health is of great interest to scholars, managers and health professionals. There is continuously growing expenditure in developed health systems, with increasing resource needs alongside unwarranted variations in both access to and outcomes from healthcare. A number of leading organisations, programmes and research themes seek to tackle issues of poor value in health, providing theoretical frameworks and practical responses for different levels in health systems.<br><br>A key element of such initiatives is to be able to measure the value provided by healthcare investment. Traditional measures of healthcare performance based on volumes of activity or specific clinical markers are not well suited to measuring this value; accurately measuring what matters to patients and deriving data and insights from these measures is an important step in many approaches to increasing value in healthcare. The patient voice has a critical role in this measurement. A helpful model for capturing the patient voice is provided by Patient Reported Outcome Measures (PROMs) and Patient Reported Experience Measures (PREMs), validated survey tools which collect information directly from patients about a range of disease specific and general health and wellbeing markers, preferences, and experiences of services. Their collection is mandated in a number of health systems, and they are used in a range of settings in the delivery of health and care, as well as in research. However, despite the availability of technologies to collect and analyse large volumes of such data, their use is not widespread. A key challenge is that data are (or can be) collected, but are not used to improve services. This thesis explores how PROMs and PREMs can be used in managerial systems to promote higher value care. <br><br>Five research questions are explored, seeking to address the totality of the value creation cycle of the use of performance information: the collection of meaningful measures; data aggregation to appropriate units; translation and analysis; displaying the findings and information resulting from this data; identifying problems and opportunities for action based on these insights; making changes to services or policies; and evaluating their impact – which then feeds into approaches to collecting meaningful measures. <br><br>Chapter 2 explores RQ1, What are all the ways in which PREMs are used as performance information at all levels (micro, meso, macro) in health systems? This question is addressed through a narrative review, based on a systematic search of the literature following the Joanna Briggs Institute methodology for systematic scoping reviews. The majority of identified papers describe uses of PREMs focussed on improving the quality of front-line care, with additional uses in quality-based financing or organisational performance improvement, with few papers addressing national and international monitoring and benchmarking. Considering all uses together with reference to the levels of data aggregation and actions of performance information, some limited evidence was found that using PREMs in public reporting and in quality-based financing models can stimulate performance improvement programmes in front-line care. There was limited evidence of impact from any improvement programmes on PREM scores or on related outcomes. <br><br>Chapter 3 explores RQ2, How are PREMs collected and used to support higher value care within and between healthcare provider organisations? This chapter describes the development of a PREMs questionnaire and administration system in two specialist paediatric hospitals, in Italy and Riga, including quantitative analysis of more than 8,200 survey responses collected from December 2018 to January 2020. This paper sets out a model for using PREMs in the cycle of value creation set out above: using PREM data to identify problems and opportunities and determine actions, make resultant changes to service delivery or policies, and evaluate their impact. <br><br>Chapter 4 explores RQ3, How do methods for collecting PREMs and PROMs enable their use in public value governance? Focussing on the maternity care pathway, this paper compares two models of digital, longitudinal data collection of both PREMs and PROMs. The two models of longitudinal collection of user-reported data were analysed using descriptive statistics, survival analysis, cost comparison, and qualitative review. This study finds that the fully digital collection of user-reported data enables high response rates to targeted surveys, potentially widening the definition of routinely collected data to include PROMs and PREMs. The point at which pregnant women or new mothers are recruited into survey models was found to be relevant for response rates and sample bias. Addressing the collection and analysis of PROMs and PREMs, the data collection models explored in this study suggest a means to collect meaningful measures for women and to use such measures to identify and evaluate opportunities for higher value care.<br><br>Chapter 5 explores RQ4, How does the presentation of patient-reported data to healthcare professionals affect their interpretation of data? Using an online survey experiment of healthcare professionals in a Latvian paediatric hospital, this study investigates the role of cognitive biases in how hospital professionals perceive organizational performance based on combinations of episodic and statistical data, with positive and negative framing, and in situations where episodic and statistical data are not in agreement. PREM data are used as the basis of the experimental scenarios. The study demonstrates that there are significant differences in perceived performance through the addition of episodic data to statistical data, and that different types of episodic data additions had different magnitudes of effect. The suggestion that the underlying accessibility of information can be seen as impacting judgements in line with the representativeness heuristic has implications for understanding the value creation cycle of performance information, highlighting the importance of considering the ways in which data are presented in determining subsequent changes to policy or delivery, and necessitating a thoughtful approach to presenting performance reports. <br><br>Lastly, Chapter 6 addresses RQ5, What insights can the collection of PREMs at scale provide into what matters most to patients in times of crisis such as the COVID-19 pandemic? A continuous and ongoing cross-sectional web survey of hospitalisation experiences in Tuscany and Veneto enabled investigation of data directly prior to and during the pandemic situation, with multilevel and multivariate logistic regression models developed to identify factors influencing satisfaction and willingness-to-recommend before and during the pandemic. This analysis found that patient reported experience actually improved in the pandemic period, with the highest scores in the worst affected areas. To explain this phenomenon, the study suggests the new concept of ‘reverse compassion’ emerged through the pandemic, driven by individuals’ awareness of and engagement in the impacts of the pandemic, which in turn shaped their experiences of hospitalisation such that overall experience scores went up in the pandemic. The study also identifies that PREMs offer a mechanism to provide feedback to health professionals by sharing the results of patient surveys back with frontline staff and managers in a timely way; healthcare managers can thus utilise patients’ positive narratives of care to reward and motivate professionals, which is particularly relevant in a pandemic situation in which normal personal communication is impossible. <br><br>In totality, the research chapters included in this thesis seek to illustrate the role of patient reported data at each stage of the value creation cycle set out in the introduction. Each phase of the cycle is addressed, with a range of methods and approaches used to seek to provide a robust and comprehensive exploration of the role of the patient voice in managerial systems to create higher value care. <br>