Economic Incentives in General Practice: the Impact of Pay for Participation Programs on Diabetes Care.

Financial incentives are increasingly adopted to improve allocative efficiency and quality in primary care. Although it has been recognised that incentive-based remuneration schemes can have an impact on GP behaviour, there is still weak empirical evidence on the extent to which such programs influence healthcare outcomes and on the degree of physicians’ responsiveness to their introduction. This problem reflects the lack of adequate empirical data but also the complexity of general practice systems where many confounding and institutional factors are likely to influence physician behaviour. Given this background, we investigate the impact on quality of care of the introduction of pay for participation incentives in primary care contracts in the Italian region Emilia Romagna. We concentrate on patients affected by diabetes mellitus type 2, for which the assumption of responsibility and the adoption of clinical guidelines are specifically rewarded. We test the hypothesis that, other things equal, patients under the responsibility of GPs receiving a higher share of their income through these programs are less likely to experience hospitalisation for hyperglycaemic emergencies. To this end, we examined the combined influence of physician, organisational and patient factors through the use of multilevel modelling. Data were obtained form a large dataset made available by the Regional Agency for Health Care Services of Emilia Romagna. This dataset covers patients and GPs of the whole region and provides detailed information on healthcare consumption of the population, on the different components of GP remunerations, on morbidity levels of large groups of patients. Estimations are obtained for the year 2003

Vertical integration and contractual network in the cardiovascular sector: the experience of the Italian region Emilia Romagna

OBJECTIVE: We analysed the integrated planning model adopted by the Italian region Emilia Romagna in year 2000 to cover the entire range of treatment of cardiovascular disease. This model, called “hub and spoke”, provides for the transfer of patient care and treatment from peripheral units (the spokes) to central units (the hubs) once a certain complexity threshold has been reached. METHODS: We examined inter-temporal variations in patients flows for the selection/referral and follow-up phases between cardiac surgery and cardiology units during two periods characterised by different organisational set-ups, in order to reflect on the progress being made in the organisation of the network. The database consisted of regional records of hospital discharges during the 1997–2001 period. RESULTS: The investigation pointed to the achievement of a good degree of coordination between structures at different levels of specialisation in the case of cardiac surgery, for which six centres were selected already in 1996. On the other hand, the more recent introduction of a hierarchical system for interventional cardiology points to the prevalence of operations on patients previously treated within the same centre, to admissions by direct access, and to follow-up mainly conducted within the hub providing the initial service. CONCLUSIONS: Despite the progress made towards the more effective rationalisation of the health care network, there is still room for improvement in relations between different centres, in particular with regard to the clearer definition of the roles and interdependence of those intermediate-level centres located between the hub centres and basic healthcare facilities

INDIVIDUAL VARIATIONS IN MONITOR HYPOTHESIS OF MICRO TEACHING STUDENTS

The paper aims to find out the types of users in performing English as a second language and to figure out principal conditions that might affect students monitoring process as proposed by Krashen (1982). Two research problems were formulated, namely: First, what individual variations are shown by students in the Micro Teaching class? Second, to what extent do Micro teaching students regard the three principal conditions in the monitor hypothesis? Both qualitative and quantitative methods were used. The qualitative method of data collection was participant observation. Nineteen students Micro Teaching videos were recorded to be observed to answer the first research problem. The quantitative method was applied through a questionnaire to answer the second research problem. An interview was also done to support the analysis of the questionnaire. The results showed that only two types of monitor users occurred in Micro Teaching Class A. The two types were monitor under-users, who were not aware of the conscious checking, and monitor over-users, who seemed to consciously check their L2 output

EFL Pre-service Teachers’ Leadership Project Practices in Indonesia's Teacher Professional Development Program

Indonesia's Ministry of Education has integrated the Leadership Project course into the Pendidikan Profesi Guru (PPG) program, emphasizing the development of professional qualifications and leadership skills among EFL pre-service teachers. This study scrutinizes the influence of both conceptual and practical frameworks of the course on cultivating leadership competencies. It poses two pivotal questions: Firstly, how do pre-service EFL teachers perceive these frameworks within leadership projects? Secondly, what challenges do they face in executing these projects effectively? Utilizing an explanatory mixed-methods design, the study collated and analyzed data from 31 participants through surveys and inductive thematic coding. It revealed that while EFL pre-service teachers have a positive reception of leadership involving collective knowledge and change initiation, they also report significant hurdles. Implementing complex frameworks like Sustainability NEWS (Nature, Economy, Well-being, Society) and Appreciative Inquiry presented difficulties, predominantly due to time limitations and communication barriers with target groups. Furthermore, a gap in understanding the conceptual underpinnings led to complications in the planning and sustainable implementation of projects, exacerbated by tight schedules and financial restrictions. Feedback from participants highlighted a need for program enhancements, suggesting refined policies, more rigorous consultation processes, and an enriched focus on reflective practices. The study offers valuable insights into the perceptions of EFL pre-service teachers regarding leadership programs

THE PERCEIVED IMPACT OF MICRO AND MACRO CONTEXTUAL FACTORS ON THE TEACHERS’ PROFESSIONAL IDENTITY DEVELOPMENT IN THE INDONESIAN RURAL AREA

The primary goal of this paper is to understand the extent to which the significance of macro and micro contextual factors influence rural teachers' professional identity development in Manggarai, NTT. Qualitative methods were employed, involving four rural teachers who shared their perspectives through an open-ended online questionnaire. The findings revealed a positive attitude towards factors such as effective communication with students and colleagues, recognition, and access to training opportunities for professional support. Unstructured interviews were conducted to delve deeper into how these factors influenced the teachers' professional identity construction and development in practice. The results indicated that, apart from the national examination due to educational reforms, the macro-contextual factors played a supportive role in the cognitive dimension, emphasizing the teachers' desire for professional growth. Despite expressing dissatisfaction with administrative demands and supervision, the participants valued the positive experiences derived from both factors. The study's focus on both micro and macro contextual factors may limit the depth of understanding regarding their specific impacts on professional identity, requiring future research to explore individual factors in greater detail. Additionally, the use of senior teachers in rural areas as participants may restrict generalizability, suggesting the need for diverse participants to capture variations in perceptions and practices across different settings

Reorganizing territorial healthcare to avoid inappropriate ED visits: does the spread of Community Health Centres make Walk-in-Clinics redundant?

BACKGROUND: Community care has recently been restructured with the development of Community Health Centres (CHCs), forcing a general rethink on the survival of previous organizational solutions adopted to reduce inappropriate ED access, for example Walk-in-Clinics (WiCs). METHODS: We focus on the Italian Emilia-Romagna Region that has made huge investments in CHC development, whilst failing to proceed at a uniform rate from area to area. Estimating panel count data models for the period 2015-2018, we pursue two goals. First we test the existence of a "CHC effect", choosing five urban cities with different degree of development of the CHC model and assessing whether, all else being equal, patients treated by GPs who have their premises inside the CHC show a lower need to seek inappropriate care (Aim 1). Second, we focus our attention on Walk-in-Clinics, investigating the long-established WiC in the city of Parma that currently coexists with three CHCs recently established in the same catchment area. In this case we try to assess whether, and to what extent, the progressive development of the CHCs in the city of Parma has been affecting the dynamics of WiC access (Aim 2). RESULTS: As regards Aim 1, we show that CHCs reduce the probability of inappropriate patient access to emergency care. As regards Aim 2, in the city of Parma patients whose GP belongs to the CHC are less likely to visit the WiC on a workday, with no significant change during the weekend when CHCs are closed, questioning the need to maintain them both in the same area when the CHC model is fully implemented. CONCLUSIONS: Our results confirm the hypothesis that expanding access to primary care settings diminishes inappropriate ED use. In addition, our findings suggest that where CHCs and WiCs coexist in the same area, it may be advisable to implement strategies that bring WiC activities into step with CHC-based general primary care reforms to avoid duplication