Denne artikel viser, hvordan diagnoser indgår som centrale komponenter i en styrings-infrastruktur på sundhedsområdet. Herved opnås en forståelse af diagnoser som ’styrings-hybrider’, som på en og samme tid betegner patienters lidelser og deres regnskabsmæssige værdi i systemer af Diagnose-Relaterede Grupper (DRG). DRG er et internationalt udbredt system til at knytte patienter og deres behandlingsomkostninger sammen i faste kategorier med henblik på at måle hospitalers produktivitet. Med afsæt i Science-Technology-Studies (STS)-feltet analyserer artiklen, hvorledes diagnoser overskrider deres kliniske funktioner, og transformeres til DRG i en styrings-infrastruktur, der forbinder stat, regioner og hospitalsafdelinger. Formålet er at bidrage til en forståelse af diagnosers rolle som infrastrukturerende og således som både dele af en infrastruktur og som performative elementer med væsentlige samfundsmæssige betydninger og funktioner. Artiklen præsenterer analyser af (i) hvorledes diagnoser spiller en central rolle i et historisk skifte i magtforholdet mellem lægefaglige og stat, (ii) hvordan behandlingen af diagnoser med DRG bliver et administrativt anliggende, der kræver nye særskilte kompetencer og funktioner, (iii) hvordan diagnoser som grundkomponenter i DRG muliggør finansieringsmodeller og forfølgelsen af en række styringsmæssige mål, som førhen ikke var mulige, og (iiii) hvordan DRG-systemet har afstedkommet kritik af dets effekter som incitamentssystem. Endeligt reflekterer artiklen over, hvordan DRG-systemet alternativt kan anskues som en samfundsudviklende infrastruktur, idet det forsamler og skaber gensidigt involverende interaktioner imellem politiske, administrative og sundhedsprofessionelle domæner. En sådan indsigt bidrager til en udvidet forståelse af infrastrukturers roller som aktører snarere end blot redskaber i samfundet.Diagnoses as governance hybrids: Diagnosis related groups in healthcareThis paper analyses how diagnoses comprise a central component in the governance infrastructure of health care. A view upon diagnoses as ‘governance hybrids’ enables a perspective that sees diagnoses simultaneously as designating patients’ diseases and their accountable value in the system of Diagnosis Related Groups (DRG). DRG is an internationally widespread system that categorises patients into groups that are clinically meaningful and have approximately the same average costs. Based on Science-Technology-Society studies (STS), the paper analyses how diagnoses transgress their clinical functions and are transformed into DRG in a governance infrastructure that connects the state, regions and hospital departments. The aim is to contribute to an understanding of diagnoses as infrastructuring and hence as both parts of an infrastructure and as performative elements with societal consequences. The paper presents analyses of (i) how diagnoses play a central role in a historical change in the power relations between clinicians and the state, (ii) how processing of diagnoses through DRG becomes an administrative matter requiring new special competences and functions, (iii) how diagnoses as part of DRG enables financial modeling and pursuance of governance goals that were not previously possible, and finally (iv) how the DRG system has spurred criticism due to its perceived effects as an incentive system. Lastly, the paper reflects upon how the DRG system can be regarded as an infrastructure that develops and constitutes society, because it gathers and creates mutually involving interactions between political, administrative and healthcare professional domains. Thus infrastructures such as DRG are not only tools, but also societal actors.
The 2018 Declaration of Astana reemphasized the importance of primary health care and its role in achieving universal health coverage. While there is a large amount of literature on the economic aspects of delivering primary care services, there is a need for more comprehensive overviews of this evidence. In this article, we offer such an overview. Evidence suggests that there are several strategies involving coverage, financing, service delivery, and governance arrangements which can, if implemented, have positive economic impacts on the delivery of primary care services. These include arrangements such as worker task‐shifting and telemedicine. The implementation of any such arrangements, based on positive economic evidence, should carefully account for potential impacts on overall health care access and quality. There are many opportunities for further research, with notable gaps in evidence on the impacts of increasing primary care funding or the overall supply of primary care services. Context The 2018 Declaration of Astana reemphasized the importance of primary health care and its role in achieving universal health coverage. To strengthen primary health care, policymakers need guidance on how to allocate resources in a manner that maximizes its economic benefits. Methods We collated and synthesized published systematic reviews of evidence on the economic aspects of different models of delivering primary care services. Building on previous efforts, we adapted existing taxonomies of primary care components to classify our results according to four categories: coverage, financing, service delivery, and governance. Findings We identified and classified 109 reviews that met our inclusion criteria according to our taxonomy of primary care components: coverage, financing, service delivery, and governance arrangements. A significant body of evidence suggests that several specific primary care arrangements, such as health workers' task shifting and telemedicine, can have positive economic impacts (such as lower overall health care costs). Notably absent were reviews on the impact of increasing primary care funding or the overall supply of primary care services. Conclusions There is a great opportunity for further research to systematically examine the broader economic impacts of investing in primary care services. Despite progress over the last decade, significant evidence gaps on the economic implications of different models of primary care services remain, which could help inform the basis of future research efforts.
Background In 2018, the concept of clusters was introduced as a new model for data-driven quality improvement in general practice in Denmark. However, there is little research on the development and implementation of general practice clusters. The study explores how the cluster coordinators responsible for leading the clusters forward enacted and experienced their role during the early years of the clusters with attention to the challenges and enablers perceived in the process. Methods Qualitative, semi-structured interviews with 25 cluster coordinators from clusters that had carried out at least two meetings on a specific professional topic. The coordinators represented clusters of varying sizes and different geographic locations. Key topics in the interview guide were the development and structure of the cluster, the role of the coordinator, obtainment of data for the meetings, the role of external support, the form and content of the meetings, the participation and engagement of the members. A thematic analysis – shaped by the original aims and categories of the study while also being open to emerging themes – was performed on the transcribed interview material. Results Important enablers in the process of developing the clusters included the positive engagement of the GPs, the support offered by regional quality units and a national quality organisation for general practice, and the funding provided by the formal cluster framework. Challenges initially included setting up the clusters administratively and translating the open cluster concept into a local, workable model; and later obtaining relevant data for the cluster meetings and facilitating peer discussions about the data. Conclusion The coordinators generally experienced that the development of the clusters had progressed relatively fast with engagement from most of the participating GPs. Still, challenges with data obtainment, data analysis, and facilitation will have to be addressed ongoingly. Future research should investigate learning processes at the cluster meetings and how the clusters impact clinical practice and collaborative relations between general practice and other health care providers.
In this paper, we propose a cosmopolitical approach to, and understanding of, data, based on the work of Isabelle Stengers. This entails appreciating data as constituted through multiple actors and actions, and, accordingly, as something capable of producing unanticipated, surprising consequences. Cosmopolitics helps us think about data, and datafication, as actors in a more-than-human world in ways that transgress a common and widespread perception of data as either neutral, objective and representational or as socially constructed, perspectivist and endowed with human politics. The argument is thus that data and datafication change practices and can bring forth novel layers and qualities of those practices. We explore data through a cosmopolitical approach using two empirical examples generated during 2013-2017, where the authors carried out ethnographic fieldwork in a project on governing and managing healthcare data. We conclude by proposing the term cosmo-data-politics and discuss the implications of this neologism.
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