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

Document Type : Review Article


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

2 NHS Confederation, London, UK


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.

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.

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.

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.


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


Main Subjects

  1. Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Aff (Millwood). 2008;27(3):759-769. doi:10.1377/hlthaff.27.3.759
  2. Pettigrew AM. The awakening giant: continuity and change in Imperial Chemical Industries. Chichester: Wiley Blackwell; 1985.
  3. Academy of Medical Royal Colleges/NHS Confederation Decisions of Value: summary of findings. Accessed November 17, 2015.
  4. Beauvais B, Wells R. Does money really matter? A review of the literature on the relationships between healthcare organization finances and quality. Hosp Top. 2006;84(2):20-28. doi:10.3200/htps.84.2.20-29
  5. Williams I. Organizational readiness for innovation in health care: some lessons from the recent literature. Health Serv Manage Res. 2011;24(4):213-218. doi:10.1258/hsmr.2011.011014
  6. Brown P, Alaszewski A, Pilgrim D, Calnan M. The quality of interaction between managers and clinicians: a question of trust. Public Money Management. 2011;31(1):43-50. doi:10.1080/09540962.2011.545546
  7. Brehmer B. Dynamic decision making: human control of complex systems. Acta Psychol (Amst). 1992;81(3):211-241.
  8. Robert G, Harlock J, Williams I. Disentangling rhetoric and reality: an international Delphi study of factors and processes that facilitate the successful implementation of decisions to decommission healthcare services. Implement Sci. 2014;9:123. doi:10.1186/s13012-014-0123-y
  9. Lin V, Gibson B. Evidence-based health policy. Melbourne, VIC: Oxford University Press; 2003.
  10. Simon HA. Information-processing theory of human problem solving.  Handbook Learning Cognitive Processes. 1978;5:271-295.
  11. McCaughey D, Bruning NS. Rationality versus reality: the challenges of evidence-based decision making for health policy makers. Implement Sci. 2010;5:39. doi:10.1186/1748-5908-5-39
  12. Davis JH. Group decision and social interaction: a theory of social decision schemes.  Psychol Rev. 1973;80(2):97-125. doi:10.1037/h0033951
  13. Kahneman D, Tversky A. Prospect Theory: An Analysis of Decision under Risk. Econometrica. 1979;47(2):263-291. doi:10.2307/1914185
  14. Reyna VF, Brainerd CJ. Fuzzy-trace theory and framing effects in choice: Gist extraction, truncation, and conversion. J Behav Decis Mak. 1991;4(4):249-262. doi:10.1002/bdm.3960040403
  15. Dobrow MJ, Goel V, Upshur RE. Evidence-based health policy: context and utilisation. Soc Sci Med. 2004;58(1):207-217.
  16. Parayitam S, Phelps LD, Olsen BJ. Strategic decision‐making in the healthcare industry: the effects of physician executives on decision outcomes. Management Research News. 2007;30(4):283-301. doi:10.1108/01409170710736329
  17. Shayo EH, Norheim OF, Mboera LE, et al. Challenges to fair decision-making processes in the context of health care services: a qualitative assessment from Tanzania. Int J Equity Health. 2012;11:30. doi:10.1186/1475-9276-11-30
  18. Goll I, Rasheed AA. The Relationships between Top Management Demographic Characteristics, Rational Decision Making, Environmental Munificence, and Firm Performance. Organization Studies. 2005;26(7):999-1023. doi:10.1177/0170840605053538
  19. Shepherd NG, Rudd JM. The influence of context on the strategic decision-making process: a review of the literature. Int J Management Reviews. 2014;16(3):340-364. doi:10.1111/ijmr.12023
  20. Suchman MC. Managing legitimacy: strategic and institutional approaches.  Acad Manage Rev. 1995;20(3):571-610. doi:10.5465/AMR.1995.9508080331
  21. Pye A, Pettigrew A. Studying Board Context, Process and Dynamics: Some Challenges for the Future. Br J Manag. 2005;16(s1):S27-S38. doi:10.1111/j.1467-8551.2005.00445.x
  22. Bate SP, Mendel P, Robert G. Organising for quality: the improvement journeys of leading hospitals in Europe and the United States. Oxford: Radcliffe Publishing, 2008.
  23. Squires JE, Graham ID, Hutchinson AM, et al. Identifying the domains of context important to implementation science: a study protocol. Implement Sci 2015;10(1):135. doi:10.1186/s13012-015-0325-y
  24. Khan K, Terriet G, Sowden A, Kleijnen J. Undertaking systematic reviews of research on effectiveness: CRD's guidance for carrying out or commissioning reviews. UK NHS Centre Reviews Dissemination; 2008.
  25. Mays N, Pope C, Popay J. Systematically reviewing qualitative and quantitative evidence to inform management and policy-making in the health field. J Health Serv Res Policy. 2005;10 Suppl 1:6-20. doi:10.1258/1355819054308576
  26. Eddama O, Coast J. A systematic review of the use of economic evaluation in local decision-making. Health Policy. 2008;86(2-3):129-141. doi:10.1016/j.healthpol.2007.11.010
  27. Williams I, McIver S, Moore D, Bryan S. The use of economic evaluations in NHS decision-making: a review and empirical investigation. Health Technol Assess. 2008;12(7):iii.
  28. Fraser KD, Estabrooks C. What factors influence case managers' resource allocation decisions? A systematic review of the literature. Med Decis Making. 2008;28(3):394-410. doi:10.1177/0272989x07312709
  29. Vuorenkoski L, Toiviainen H, Hemminki E. Decision-making in priority setting for medicines--a review of empirical studies. Health Policy. 2008;86(1):1-9. doi:10.1016/j.healthpol.2007.09.007
  30. Miller R, Williams I, Allen K, Glasby J. Evidence, insight, or intuition? Investment decisions in the commissioning of prevention services for older people. J Care Serv Manag. 2013;7(4):119-127. doi:10.1179/1750168714Y.0000000027
  31. Abelson J. Understanding the role of contextual influences on local health-care decision making: case study results from Ontario, Canada. Soc Sci Med. 2001;53(6):777-793.
  32. Bazzoli GJ, Clement JP, Lindrooth RC, et al. Hospital financial condition and operational decisions related to the quality of hospital care. Med Care Res Rev. 2007;64(2):148-168. doi:10.1177/1077558706298289
  33. Finocchiaro Castro M, Guccio C, Pignataro G, Rizzo I. The effects of reimbursement mechanisms on medical technology diffusion in the hospital sector in the Italian NHS. Health Policy. 2014;115(2-3):215-229. doi:10.1016/j.healthpol.2013.12.004
  34. Denis JL, Champagne F, Contandriopoulos AP, Cazale L. Determinants of a merger in a publicly-funded health system: a political-economy perspective. Int J Health Plann Manage. 1992;7(2):79-101.
  35. Dranove D, Hughes EF, Shanley M. Determinants of HMO formulary adoption decisions. Health Serv Res. 2003;38(1 Pt 1):169-190.
  36. Fischer KE. A systematic review of coverage decision-making on health technologies-evidence from the real world. Health Policy. 2012;107(2-3):218-230. doi:10.1016/j.healthpol.2012.07.005
  37. Fraser KD, Estabrooks C, Allen M, Strang V. Factors that influence case managers' resource allocation decisions in pediatric home care: an ethnographic study. Int J Nurs Stud. 2009;46(3):337-349. doi:10.1016/j.ijnurstu.2008.10.001
  38. Hensher M, Fulop N. The influence of health needs assessment on health care decision-making in London health authorities. J Health Serv Res Policy. 1999;4(2):90-95. doi:10.1177/135581969900400206
  39. Kisa A, Kavuncubasi S, Ersoy K. The influence of financial officers on the decision-making process in health facilities: a study in Ankara. Health Care Manag (Frederick). 2006;25(1):37-42.
  40. Li L, Benton WC. Hospital capacity management decisions: Emphasis on cost control and quality enhancement. Eur J Oper Res. 2003;146(3):596-614. doi:10.1016/S0377-2217(02)00225-4
  41. Li L, Benton WC. Hospital technology and nurse staffing management decisions. Journal of Operations Management. 2006; 24 (5): 676–691.
  42. Paudyal V, Hansford D, Cunningham S, Stewart D. Community pharmacists' adoption of medicines reclassified from prescription-only status: a systematic review of factors associated with decision making. Pharmacoepidemiol Drug Saf. 2012;21(4):396-406. doi:10.1002/pds.3219
  43. Polisena J, Clifford T, Elshaug AG, Mitton C, Russell E, Skidmore B. Case studies that illustrate disinvestment and resource allocation decision-making processes in health care: a systematic review. Int J Technol Assess Health Care. 2013;29(2):174-184. doi:10.1017/s0266462313000068
  44. Roggenkamp SD, White KR, Bazzoli GJ. Adoption of hospital case management: economic and institutional influences. Soc Sci Med. 2005;60(11):2489-2500. doi:10.1016/j.socscimed.2004.11.010
  45. Sosnowy CD, Weiss LJ, Maylahn CM, Pirani SJ, Katagiri NJ. Factors affecting evidence-based decision making in local health departments. Am J Prev Med. 2013;45(6):763-768. doi:10.1016/j.amepre.2013.08.004
  46. Wright B, Martin GP. Mission, margin, and the role of consumer governance in decision-making at community health centers. J Health Care Poor Underserved. 2014;25(2):930-947. doi:10.1353/hpu.2014.0107
  47. Berta W, Laporte A, Kachan N. Unpacking the relationship between operational efficiency and quality of care in Ontario long-term care homes. Can J Aging. 2010;29(4):543-556. doi:10.1017/s0714980810000553
  48. Foot C, Sonola L, Maybin, J, Naylor C. Service-line management. Can it improve quality and efficiency? London: Kings Fund; 2012.
  49. Davies HT, Mannion R, Jacobs R, Powell AE, Marshall MN. Exploring the relationship between senior management team culture and hospital performance. Med Care Res Rev. 2007;64(1):46-65. doi:10.1177/1077558706296240
  50. Stock GN, McFadden KL, Gowen CR. Organizational culture, critical success factors, and the reduction of hospital errors. Int J Prod Econ. 2007;106(2):368-392.
  51. 51 Konteh FH, Mannion R, Davies HT. Clinical governance views on culture and quality improvement. Clinical Governance: An International Journal. 2008;13(3):200-207. doi:10.1108/14777270810892610
  52. Papadakis VM, Lioukas S, Chambers D. Strategic decision-making processes: the role of management and context. Strategic Management Journal. 1998;19(2):115-147. doi:10.1002/(SICI)1097-0266(199802)19:23.0.CO;2-5
  53. Keinan G, Friedland N, Ben-Porath Y. Decision making under stress: Scanning of alternatives under physical threat. Acta Psychol. 1987;64(30:219-228. doi:10.1016/0001-6918(87)90008-4
  54. Starcke K, Wolf OT, Markowitsch HJ, Brand M. Anticipatory stress influences decision making under explicit risk conditions. Behav Neurosci. 2008;122(6):1352-1360. doi:10.1037/a0013281
  55. Zinn JO. Heading into the unknown: Everyday strategies for managing risk and uncertainty. Health Risk Society. 2008;10(5):439-450. doi:10.1080/13698570802380891
  56. Pfister HR, Bohm,G. The multiplicity of emotions: a framework of emotional functions in decision making.  Judgm Decis Mak. 2008;3(1):5-17.
  57. Bellman RE, Zadeh LA. Decision-making in a fuzzy environment. Manage Sci. 1970;17(4):B-141-B-164. doi:10.1287/mnsc.17.4.B141
  58. Zey M. Criticisms of rational choice models. In Zey, M. Decision-making: alternatives to rational choice models. Newbury Park, CA: Sage Publications; 1992: 10-31.
  59. Nalbandian J, Klingner DE. Integrating Context and Decision Strategy: A Contingency Theory Approach to Public Personnel Administration. Adm Soc. 1980;12(2):178-202. doi:10.1177/009539978001200204
  60. Mousavi S, Garrison J. Toward a transactional theory of decision making: creative rationality as functional coordination in context. Journal Economic Methodology. 2003;10(2):131-156. doi:10.1080/1350178032000071039
  61. Williams I. Institutions and health care rationing: the example of health care coverage in the English National Health Service. Policy Polit. 2013;41(2):223-239. doi:10.1332/030557312X655477
  • Receive Date: 04 May 2017
  • Revise Date: 10 November 2017
  • Accept Date: 24 January 2018
  • First Publish Date: 01 August 2018