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19 - Improving clinical decision making

Published online by Cambridge University Press:  06 December 2010

Jean-Pierre Unger
Institute of Tropical Medicine Antwerp
Pierre De Paepe
Institute of Tropical Medicine Antwerp
Kasturi Sen
Institute of Tropical Medicine Antwerp
Werner Soors
Institute of Tropical Medicine Antwerp
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Part 1: Non-managed care techniques to improve clinical practice


In recent years managed care became a promise of cost control and reduction of unnecessary services utilization, especially in countries with very limited resources. Most LMICs included it early in their reform packages (Tollman et al., 1990). In spite of scarce empirical evidence on the implementation of managed care techniques in this setting (Luck & Peabody, 2002) and intense debates surrounding their introduction in countries such as the USA (Christianson et al., 2005; Simonet, 2005), these techniques were increasingly exported to LMICs.

In this chapter we briefly analyze the results of the introduction of managed care techniques in different environments, explore issues related to the resulting loss of autonomy in clinical practice and offer alternative techniques to improve quality of health care.

What is managed care and what are its results?

The literature offers different approaches and definitions of managed care, probably because it does not convey one single, common concept, but a set of principles and interwoven practices (born in the 1980s in the USA to control costs).

Managed care techniques aim at providing incentives for productivity and efficiency while improving quality of services. They should be distinguished from the organizations which implement them. In this chapter we will attempt to focus on the former and address, in the first instance, clinical mechanisms designed to improve clinical decision making.

International Health and Aid Policies
The Need for Alternatives
, pp. 225 - 239
Publisher: Cambridge University Press
Print publication year: 2010

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Atherton, F., Mbekem, G., & Nyalusi, I. (1999). Improving service quality: Experience from the Tanzania family health project. International Journal for Quality in Health Care, 11(4), pp. 353–6.CrossRefGoogle ScholarPubMed
Bennett, L., Miller, D., & Ross, M. (1995). Health Workers and AIDS: Research, Intervention and Current Issues in Burnout and Response. Chur, Switzerland: Harwood Academic Publishers GmbH.Google Scholar
Björk, M., Johansson, R., & Kanji, N. (1992). Improving the quality of primary care services in Angola. Health Policy and Planning, 7, pp. 290–5.CrossRefGoogle Scholar
Christianson, J. B., Warrick, L. H., & Wholey, D. R. (2005). Physicians' perceptions of managed care: A review of the literature. Medical Care Research and Review, 62(6), pp. 635–75.CrossRefGoogle ScholarPubMed
Crossley, D., Myres, M. P., & Wilkinson, G. (1992). Assessment of psychological care in general practice. British Medical Journal, 305(6865), pp. 1333–6.CrossRefGoogle ScholarPubMed
Ellsbury, K., Montano, D., & Krafft, K. (1990). A survey of the attitudes of physician specialists toward capitation-based health plans with primary care gatekeepers. QRB Quality Review Bulletin, 16(8), pp. 294–300.CrossRefGoogle ScholarPubMed
Forsberg, B., Barros, F. C., & Victora, C. G. (2000). Developing countries needs more quality assurance: How health facility surveys can contribute. Revue de littérature, pp. 193–6.Google Scholar
Galbraith, J. R. (1973). Designing Complex Organizations. Boston: Addison-Wesley Longman Publishing Co.Google Scholar
Gold, M. (1998). Beyond coverage and supply: Measuring access to health care in today's market. Health Services Research, 33(3), pp. 625–52.Google ScholarPubMed
Grol, R., Baker, R., Wensing, M., & Jacobs, A. (1994). Quality assurance in general practice: The state of the art in Europe. Family Practice, 11(4), pp. 460–7.CrossRefGoogle Scholar
Henbest, R. J. & Fehrsen, G. S. (1992). Patient-centredness: Is it applicable outside the West? Its measurement and effect on outcomes. Family Practice, 9(3), pp. 311–7.CrossRefGoogle ScholarPubMed
Landon, B. E., Zaslavsky, A. M., Bernard, S. L., Cioffi, M. J., & Cleary, P. D. (2004). Comparison of performance of traditional Medicare vs. Medicare managed care. Journal of the American Medical Association, 291(14), pp. 1744–52.CrossRefGoogle ScholarPubMed
Leedam, E. J. (1972). Community Nursing Manual: A Guide for Auxiliary Public Health Nurses. Singapore: McGraw-Hill.Google Scholar
Lett, R. (2000). Canadian network for international surgery: Development activities and strategies. Canadian Journal of Surgery, 43(5), pp. 385–7.Google ScholarPubMed
Liaw, S. T., Young, D., & Farish, S. (1996). Improving patient-doctor concordance: An intervention study in general practice. Family Practice, 13(5), pp. 427–31.CrossRefGoogle ScholarPubMed
Loutfi, A., McLean, A. P., & Pickering, J. (1995). Training general practitioners in surgical and obstetrical emergencies in Ethiopia. Tropical Doctor, 25(Supplement 1), pp. 22–6.CrossRefGoogle ScholarPubMed
Luck, J. & Peabody, J. W. (2002). When do developing countries adopt managed care policies and technologies? Part II: Infrastructure, techniques, and reform strategies. American Journal of Managed Care, 8(12), pp. 1093–103.Google ScholarPubMed
Mechanic, D. (2001). The managed care backlash: Perceptions and rhetoric in health care policy and the potential for health care reform. Milbank Quarterly, 79(1), p. 35.CrossRefGoogle ScholarPubMed
Miller, R. H. & Luft, H. S. (2002). HMO plan performance update: An analysis of the literature, 1997–2001. Health Affairs (Millwood), 21(4), pp. 63–86.CrossRefGoogle ScholarPubMed
Mintzberg, H. (1988). La Estructura De Las Organizaciones. Barcelona: Ariel Economía.Google Scholar
Omaswa, F., Burnham, G., Baingana, G., Mwebesa, H., & Morrow, R. (1997). Introducing quality management into primary health care services in Uganda. Bulletin of the World Health Organization, 75(2), pp. 155–61.Google ScholarPubMed
Ortún, V. & Gervás, J. (1996). Fundamentos y eficiencia de la atención médica primaria. Médicina Clínica (Barcelona), 106(3), pp. 97–102.Google Scholar
Peiró, S. (2003). De la gestión de lo complementario a la gestión integral de la atención de salud: gestión de enfemedades e indicadores de actividad. In: Ortún, V., ed. Gestión Clínica y Sanitaria. Barcelona: Masson, pp. 17–89.Google Scholar
Pratt, R. (2003). HIV and AIDS: A Foundation for Nursing and Healthcare Practice. London: Hodder Arnold.CrossRefGoogle Scholar
,Public Health Research and Training Unit of the ITM. (1989). The training of district medical officers in the organisation of health services: A methodology tested in Senegal. Health Policy and Planning, 4, pp. 148–56.CrossRefGoogle Scholar
Remler, D. K., Donelan, K., Blendon, R. J., et al. (1997). What do managed care plans do to affect care? Results from a survey of physicians. Inquiry-the Journal of Health Care Organization Provision and Financing, 34(3), pp. 196–204.Google ScholarPubMed
Sekerka, L. E. & Chao, J. (2005). Peer coaching as a technique to foster professional development in clinical ambulatory settings. Journal of Continuing Education in the Health Professions, 23(1), pp. 30–7.CrossRefGoogle Scholar
Sharma, R. K. & Dash, V. B. (2006). Caraka Samhita. Varanasi, Chowkamba Press.Google Scholar
Shortell, S. M., Gillies, R. R., Anderson, D. A., Erickson, K. M., & Mitchell, J. B. (2009). Remaking Health Care in America. 2nd edn. San Fransisco: Jossey-Bass.Google Scholar
Simmons, J. A. (1975). Nursing Psychiatrique: Guide De Relation Infirmière-Client. Montréal: Éditions HRW.Google Scholar
Simonet, D. (2005). Patient satisfaction under managed care. International Journal of Health Care Quality Assurance Incorporating Leadership in Health Services, 18(6–7), pp. 424–40.CrossRefGoogle ScholarPubMed
Sohier, N., Frejacques, L., & Gagnayre, R. (1999). Design and implementation of a training programme for general practitioners in emergency surgery and obstetrics in precarious situations in Ethiopia. Annals of the Royal College of Surgeons of England, 81(6), pp. 367–75.Google ScholarPubMed
Starfield, B. (1998). Primary Care. Balance Between Healthcare Needs, Services and Technology. New York: Oxford University Press.Google Scholar
Tollman, S., Schopper, D., & Torres, A. (1990). Health maintenance organisations in developing countries: What can we expect?Health Policy and Planning, 5(2), pp. 149–60.CrossRefGoogle Scholar
Vargas, Lorenzo I..(2009). Barreras en el acceso a la atención en salud en modelos de competencia gestionada: un estudio de caso en Colombia, Bellaterra, España: Universidad Autónoma de Barçalona.Google Scholar
Vargas, L. I. (2002). La utilización del mecanismo de asignación per cápita: la experiencia de Cataluña. Cuadernos de Gestión, 8(4), pp. 167–78.Google Scholar
Weed, L. L. (1969). Medical Records, Medical Education and Patient Care. Chicago: Year Book Medical Publishers.Google Scholar
Young, G. J., Charns, M. P., Desai, K., et al. (1998). Patterns of coordination and clinical outcomes: A study of surgical services. Health Services Research, 33(5), pp. 1211–36.Google ScholarPubMed
Baker, R. (1994). What is interface audit?Journal of the Royal Society of Medicine, 87(4), pp. 228–31.Google ScholarPubMed
Baker, R., Robertson, N., & Farooqi, A. (1995). Audit in general practice: Factors influencing participation. British Medical Journal, 311(6996), pp. 31–4.CrossRefGoogle ScholarPubMed
Berger, A. (1998). Why doesn't audit work? [editorial]. British Medical Journal, 316(7135), pp. 875–6.CrossRefGoogle Scholar
Bryce, F. C., Clayton, J. K., Rand, R. J., Beck, I., Farquharson, D. I., & Jones, S. E. (1990). General practitioner obstetrics in Bradford [published erratum appears in BMJ 1990 May 26; 300(6736): 1394]. British Medical Journal, 300(6726), pp. 725–7.CrossRefGoogle Scholar
Bulpitt, C. J., Daymond, M. J., & Dollery, C. T. (1982). Community care compared with hospital outpatient care for hypertensive patients. British Medical Journal (Clinical Research Ed), 284(6315), pp. 554–6.CrossRefGoogle ScholarPubMed
Christakis, D. A. & Rivara, F. P. (1998). Pediatricians' awareness of and attitudes about four clinical practice guidelines. Pediatrics, 101(5), pp. 825–30.CrossRefGoogle ScholarPubMed
Eccles, M. P., Deverill, M., McColl, E., & Richardson, H. (1996). A national survey of audit activity across the primary-secondary care interface. Quality in Health Care, 5(4), pp. 193–200.CrossRefGoogle ScholarPubMed
Gnanalingham, J., Gnanalingham, M. G., & Gnanalingham, K. K. (2001). An audit of audits: Are we completing the cycle?Journal of the Royal Society of Medicine, 94(6), pp. 288–9.CrossRefGoogle ScholarPubMed
Grol, R., Dalhuijsen, J., Thomas, S., Veld, C., Rutten, G., & Mokkink, H. (1998). Attributes of clinical guidelines that influence use of guidelines in general practice: Observational study. British Medical Journal, 317(7162), pp. 858–61.CrossRefGoogle ScholarPubMed
Hibble, A., Kanka, D., Pencheon, D., & Pooles, F. (1998). Guidelines in general practice: The new Tower of Babel?British Medical Journal, 317(7162), pp. 862–3.CrossRefGoogle Scholar
Johnston, G., Crombie, I. K., Davies, H. T., Alder, E. M., & Millard, A. (2000). Reviewing audit: Barriers and facilitating factors for effective clinical audit. Quality in Health Care, 9(1), pp. 23–36.CrossRefGoogle ScholarPubMed
,Kasongo Project Team.(1981). Le Projet Kasongo; une expérience d'organisation d'un soins de santé primaires. Annales de la Société Belge de Médecine Tropicale, 60(S1), pp. 1–54.Google Scholar
Kvamme, O. J., Olesen, F., & Samuelson, M. (2001). Improving the interface between primary and secondary care: A statement from the European Working Party on Quality in Family Practice (EQuiP). Quality in Health Care, 10(1), pp. 33–9.CrossRefGoogle Scholar
Langley, C., Faulkner, A., Watkins, C., Gray, S., & Harvey, I. (1998). Use of guidelines in primary care – practitioners' perspectives. Family Practice, 15(2), pp. 105–11.CrossRefGoogle ScholarPubMed
Mohr, J. J. & Batalden, P. B. (2002). Improving safety on the front lines: The role of clinical microsystems. Quality & Safety in Health Care, 11(1), pp. 45–50.CrossRefGoogle ScholarPubMed
Shekelle, P. G. (2002). Why don't physicians enthusiastically support quality improvement programmes?Quality & Safety in Health Care, 11(1), pp. 6.CrossRefGoogle ScholarPubMed
Singh, B. M., Holland, M. R., & Thorn, P. A. (1984). Metabolic control of diabetes in general practice clinics: Comparison with a hospital clinic. British Medical Journal (Clinical Research Ed), 289(6447), pp. 726–8.CrossRefGoogle ScholarPubMed
Szecsenyi, J. (1996). Improving care at the primary-secondary care interface: A difficult but essential task. Quality in Health Care, 5(4), pp. 191–2.CrossRefGoogle ScholarPubMed
Unger, J. P., Criel, B., Dugas, S., Vennet, J., & Roland, M. (2003). Workshop 13: EUPHA section on health services research: In search of best innovations: Comparative methods in health services research. The Local Health Systems (LHS) project in Belgium [Abstract]. European Journal of Public Health, 13(4), p. 26.Google Scholar
Westcott, R., Sweeney, G., & Stead, J. (2000). Significant event audit in practice: A preliminary study. Family Practice, 17(2), pp. 173–9.CrossRefGoogle ScholarPubMed
,WHO Working Group of Quality Assurance. (1994). Report of the WHO working group on quality assurance. Geneva: WHO. WHO/SHS/DHS/94.5.Google Scholar
Wright, J. & Wilkinson, J. (1996). General practitioners' attitudes to variations in referral rates and how these could be managed. Family Practice, 13(3), pp. 259–63.CrossRefGoogle ScholarPubMed

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