Contextual Factors Influencing Cost and Quality Decisions in Health and Care: A Structured Evidence Review and Narrative Synthesis

Document Type : Review Article

Authors

1 Health Services Management Centre, University of Birmingham, Birmingham, UK

2 NHS Confederation, London, UK

Abstract

Background
Decisions affecting cost and quality are taken across health and care but investigation of the mediating role of context in these is in its infancy. This paper presents a synthesis of the evidence on the contextual factors that influence ‘decisions of value’ – defined as those characterised by having a significant and demonstrable impact on both quality and resources – in health and care. The review considers the full range of resource/quality decisions and synthesises knowledge on the contextual drivers of these.

 
Methods
The method involved structured evidence review and narrative synthesis. Literature was identified through searches of electronic databases (HMIC, Medline, Embase, CINAHL, NHS Evidence, Cochrane, Web of Knowledge, ABI Inform/Proquest), journal and bibliography hand-searching and snowball searching using citation analysis. Structured data extraction was performed drawing out descriptive information and content against review aims and questions. Data synthesis followed a thematic approach in accordance with the varied nature of the retrieved literature.

 
Results
Twenty-one literature items reporting 14 research studies and seven literature reviews met the inclusion criteria. The review shows that in health and care contexts, research into decisions of value in health and care is in its infancy and contains wide variation in approach and remit. The evidence is drawn from a range of service and country settings and this reduces generalisability or transferability of findings. An area of relative strength in the published evidence is inquiry into factors influencing coverage and commissioning decisions in health care systems. Allocative decisions have therefore been more consistently researched than technical decisions. We use Pettigrew’s (1985) distinction between inner and outer context to structure analysis of the range of factors reported as being influential. These include: evidence/information, organisational culture and governance regimes, and; economic and political conditions.

 
Conclusion
Decisions of value in health and care are subject to range of intersecting influences that often lead to a departure from narrow notions of rational decision-making. Future research should pay greater attention to the relatively under-explored area of technical, as opposed to allocative, decision-making.

Highlights

Commentaries Published on this Paper

  • On Fundamental Premises for Addressing “Context” and “Contextual Factors” Influencing Value Decisions in Healthcare; Comment on “Contextual Factors Influencing Cost and Quality Decisions in Health and Care: A Structured Evidence Review and Narrative Synthesis”

            Abstract | PDF

  • Decisions of Value: Going Backstage; Comment on “Contextual Factors Influencing Cost and Quality Decisions in Health and Care: A Structured Evidence Review and Narrative Synthesis”

            Abstract | PDF

  • Understanding Contextual Factors in Cost, Quality and Priority Setting Decisions in Health; Comment on “Contextual Factors Influencing Cost and Quality Decisions in Health and Care: A Structured Evidence Review and Narrative Synthesis”

            Abstract | PDF

 

Authors' Response to the Commentaries

  • Influencing Decisions of Value in Health: A Response to Recent Commentaries

            Abstract | PDF

Keywords

Main Subjects

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History

  • Receive Date: 04 May 2017
  • Revise Date: 10 November 2017
  • Accept Date: 24 January 2018
  • First Publish Date: 01 August 2018

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