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Biomedical subjects

L Malcolm

Publications and source records attributed to L Malcolm.

At least 19 recordsLinked to original sources
PubMed2001

Government failure?

Explore the source record for details and available documents.

Delivery of Health Care↗
PubMed2001

Pharmaceutical management in ProCare Health Limited.

AIMS: To review pharmaceutical budget holding and management in ProCare Health Limited by; describing budget holding strategies implemented in 1995/6, identifying prescribing savings achieved, analysing variation in prescribing behaviour and comparing the findings with experience elsewhere. METHODS: With 340 members, ProCare is one of the largest and most progressive of New Zealand's independent practitioner associations (IPAs). Data were obtained for the three years 1994 to 1996 to determine pharmaceutical expenditure against budget and against national trends, by member and general medical services (GMS) consultations. RESULTS: ProCare has established a classical, quality focussed pharmaceutical management strategy. Savings against the agreed budget was 9.5% comparing 1996 with 1995 but 5.7% compared, with national trends. Wide variation in per capita and per consultation costs was not reduced and was entirely explained by prescribing volumes not drug prices. CONCLUSIONS: The most important finding is that general practitioners (GPs), working collaboratively, can establish a strategy of clinical and corporate governance which may be exerting a wide ranging influence over clinical behaviour. Although there may be doubts about the actual levels of saving these appeared to be well in excess of the financial investment in the strategy. Greater savings appear possible with a focus on addressing the large and apparently inappropriate per capita prescribing volume variation between practices. Understanding and successfully addressing this variation will be one of the key issues facing the implementation of the government's primary health care strategy.

Cost Savings↗
PubMed2000

Integrating primary and secondary care: the case of Christchurch South Health Centre.

AIMS: To study health services utilisation linkages and methodological issues in integrating primary and secondary care services for a defined general practice population (Christchurch South Health Centre, CSHC). METHODS: The Centre supplied national health index (NHI) linked data on date of birth, gender and community services card (CSC) status for 10,174 patients, and data on primary care. Secondary care providers supplied NHI linked data on specialist outpatients, emergency department usage for 1996 to 1998, and waiting lists. The Health Funding Authority (HFA) supplied NHI linked data on inpatient/daypatients for 1996 and 1997. Data were also obtained relating to community support services and long-term care. Rates of hospital utilisation for the Centre's population were standardised for comparison with national and Christchurch figures using age, gender and CSCs. Overall per capita expenditure was calculated for this population. RESULTS: Patients with CSCs constituted 31.2% of the practice population, but generated 60.8% of bed-days. Patients with high use health cards (HUHCs) constituted 8.6% of the population, but generated 42.4% of bed-days. This group was at high risk of hospitalisation over a wide range of disease categories. Standardised rates of hospital utilisation were significantly lower for the Centre's older patients, especially for bed-days, than both national and Christchurch figures. Only a small proportion of referrals to specialist outpatients, 28.2% in 1998, was from the Centre's general practitioners (GPs), the remainder being generated internally within the specialist services. The overall expenditure per capita on the Centre's population was $1012, which was substantially less than expected in comparison with national figures. CONCLUSION: The study demonstrates the importance of primary care factors in the utilisation of secondary care, especially acute hospitalisation in older patients. This needs further study as it could provide important insights into ways of reducing acute admissions. If there is to be more effective management of the primary/secondary care interface, more research and development effort is needed into the characteristics of patients at high risk of referral and admission, and how inappropriate secondary care can be averted.

Adolescent↗
PubMed2000

Laboratory expenditure in Pegasus Medical Group: a comparison of high and low users of laboratory tests with academics.

AIMS: To determine, through the use of clinical vignettes, whether low and high cost users of laboratory tests in Pegasus Medical Group (Pegasus) differed in their choice of laboratory tests from academics as a means of further investigating issues relating to quality and cost in laboratory testing. METHODS: Seven clinical vignettes were drawn up and sent to 30 selected members in Pegasus whose actual laboratory expenditure per consultation ranged from a mean of $2.3 in a low cost group (15 members) to $12.2 in a high cost group (15 members). The vignettes were also sent to 15 general practitioner academics. Respondents were requested to complete a laboratory form as to which tests they would use for each individual scenario. The answers were analysed for overall cost as well as numbers of laboratory tests requested. RESULTS: There were 14 academic responses and 13 each from the bottom and top laboratory users. Overall results for the seven vignette cases showed that low cost laboratory users would spend a total of $176.3, the academics $188.8, and the high cost users $219.5 on the cases. The mean per case costs were $25.2, $27.0 and $31.4 respectively. There was a clear tendency for high volume users of tests in each vignette to be high in others suggesting that doctor rather than patient factors were the main explanation of the variation. CONCLUSIONS: Clinical vignettes do not appear to be a useful strategy in clarifying issues related to quality and cost in laboratory utilisation. Test ordering behaviour appears, from the international literature and this study, to be determined more by personal doctor factors than by objective evidence and clinical need. Further work is needed to clarify the relationship between quality and the wide variation observed in utilisation and expenditure.

Adult↗
PubMed2000

Emerging clinical governance: developments in independent practitioner associations in New Zealand.

AIMS: To document and analyse the development of independent practitioner associations and similar groups in New Zealand. METHODS: A questionnaire was sent to the 30 independent practitioner associations in August 1998 and followed-up by a number of reminders. RESULTS: The 28 respondents (93%) represent 97% coverage of the estimated membership of independent practitioner associations and similar groups. Membership of the 28 responding organisations ranged between seven and 340, with an average of 74 members and a total of 132 employed staff. Twenty-one had appointed a chief executive officer or general manager. The respondents' most important goals were "achieving better health outcomes for patients" and "making better use of primary care resources". They reported almost total implementation of computerised age/sex registers in their practices. There was strong support for independent practitioner associations to manage the clinical activity of members, to move from historical to equitable, needs-based funding and for formal patient enrolment. The majority of respondents supported integrated and capitated primary care budgets but few supported capitated budgets for separate general medical services, laboratory and pharmaceutical services. Important recent initiatives include a wide range of integration projects and increasing involvement of local communities. CONCLUSION: Independent practitioner associations have made significant progress in increasing membership levels, in establishing a framework for managing clinical activity of members and in developing their infrastructure, including information systems. They have established a wide range of new relationships within primary care, with their communities and with primary and secondary care providers. In managing increasing amounts of public money to achieve public goals, these groups may be developing a new model of clinical governance, which could be of international importance.

Humans↗
PubMed1999

An evaluation of pharmaceutical management and budget holding in Pegasus Medical Group.

AIMS: To describe and evaluate pharmaceutical management, including budget holding, in Pegasus Medical Group (Pegasus), to determine savings being achieved, to analyse variation in prescribing behaviour and to compare the findings with national and international experience. METHODS: Trends in pharmaceutical expenditure of the 150 Pegasus' 208 members who had a continuous prescribing record for the three years ending December 1996 were compared with national trends. Expenditure per member, per consultation and per item were also analysed. RESULTS: Pegasus has implemented a comprehensive and classical pharmaceutical management strategy. This includes active personalised feedback, information sharing, peer review groups and information system development, all within an incentive framework of retained savings for new services. Although about 5% savings of total pharmaceutical expenditure were identified by the above method, the real level may be higher. Wide variation between members in their prescribing behaviour was explained almost entirely by the volume rather than the price of the drugs prescribed. Targeting of the volume issue is therefore likely to have a much more significant effect in reducing inappropriate variation. CONCLUSION: The results indicate that the achievements of Pegasus, as for other independent practitioner associations, go far beyond the modest level of pharmaceutical savings achieved. These include the development of a substantial infrastructure, peer review processes, new internal and external relationships and accountability for the management of both quality and cost in what may be styled clinical governance. Such achievements put Pegasus and other independent practitioner associations into a strong position to take on new initiatives including integration with secondary care.

Budgets↗
PubMed1999

Augmentation of killing of Escherichia coli O157 by combinations of lactate, ethanol, and low-pH conditions.

The acid tolerance of Escherichia coli O157:H7 strains can be overcome by addition of lactate, ethanol, or a combination of the two agents. Killing can be increased by as much as 4 log units in the first 5 min of incubation at pH 3 even for the most acid-tolerant isolates. Exponential-phase, habituated, and stationary-phase cells are all sensitive to incubation with lactate and ethanol. Killing correlates with disruption of the capacity for pH homeostasis. Habituated and stationary-phase cells can partially offset the effects of the lowering of cytoplasmic pH.

Animals↗
PubMed1997

Beyond ideology: the emerging roles of New Zealand's crown health enterprises.

New Zealand has experienced radical public sector restructuring over the last decade, including the corporatization and subsequent privatization of state trading units and the reform of social services, including health. In 1991 a new government proposed and then implemented more radical health reforms, which included the corporatization of state-owned provider units (23 crown health enterprises) and the creation of an internal market with purchasers (four regional health authorities) separated from providers. Interviews with chief executives of crown health enterprises suggest that provider units are seeking a wider role than envisaged, with an interest in the health needs of their populations and undertaking some purchasing on their behalf. The purchasers see a narrower role for crown health enterprises. Both purchasers and providers report that competition between providers is not particularly helpful (and with only limited opportunities for this to occur), with collaboration being seen as more useful. Providers are critical of purchasers ability to adopt a strategic approach. Unlike other aspects of New Zealand's restructuring, there appears to be a retreat from some of the more radical facets of the reforms, reflecting both the resistance of the health sector and a newly uncertain political climate.

Economic Competition↗
PubMed1996

Inequities in access to and utilisation of primary medical care services for Maori and low income New Zealanders.

AIM: To determine the rates of utilisation and expenditure on primary medical care and related services for Maori and low income New Zealanders and to compare these rates with the average for New Zealand. METHODS: Data for the 1994/95 financial year were obtained from Health Benefits Ltd (HBL) for GMS payments in community service card (CSC) categories, laboratory and pharmaceutical expenditure and utilisation of general practitioner related ACC services from ACC. Data were also obtained from various sources to fill gaps including actual general practitioner related expenditure. Eight health centres serving predominately Maori but also low income groups totalling nearly 50,000 people provided data on their practice registers, GMS type utilisation and expenditure on laboratory and pharmaceutical services. These data were age and CSC adjusted by GMS category to permit valid comparisons with the national data. RESULTS: There were an estimated 15.77 million general practitioner consultations in 1994/5, a rate of 4.46 consultations per capita. Expenditure per capita on GMS, ACC, laboratory and pharmaceutical services was estimated to be $63.07 per consultation and $281.27 per capita. By comparison the rates of utilisation in all the centres studied were substantially lower than these national figures both overall and in all CSC groups. Adjusting for age and CSC status total expenditure on primary medical care and related services for these centres was only about 40% of the national average. Total average income per consultation, including GMS, ACC and patient fees, ranged from $16.52 to $21.71 a level which, especially for patients with often complicated health problems needing prolonged consultations, was unsustainably low. CONCLUSION: This study confirms gross underutilisation of and expenditure on primary medical care and related services to Maori and other New Zealanders in poor circumstances. It also confirms what has been known by general practitioners for a long time, that they are required to subsidise many Maori and poorer patients who face financial and other barriers in accessing their services. Practices servicing poorer populations cannot subsidise these patients from their fewer better off patients. The small advantage of the CSC is largely offset by the reduced subsidy from ACC. Poor access to and utilisation of primary care services is likely to be a significant factor in the high use of hospital inpatients services by the groups studied. A radical review is required of the current problems of financial access if health services are to have a better chance of improving the health status of disadvantaged New Zealanders.

Fees, Medical↗
PubMed1996

Successful implementation of laboratory budget holding by Pegasus Medical Group.

AIMS: To evaluate the effectiveness of budget holding by Pegasus Medical Group for laboratory services expenditure and reasons for the successes observed. METHODS: Two pilot groups and a nonpilot group of general practitioners were formed with the pilots receiving active feedback, educational programmes and test form redesign within the incentive of savings being retained by the group for improved primary care services. RESULTS: Overall savings of 22.7% were achieved within the budget over a 13 month period. There was a highly significant reduction in expenditure per member especially in the mean and standard deviation of cost per consultation indicating a marked narrowing of the variance in cost between members in the pilot groups compared with the nonpilot group. CONCLUSION: The study illustrates the effectiveness of a comprehensive strategy of education, active feedback and test form redesign and especially the importance of the incentive of retaining budgetary savings for service improvements. It also illustrates the importance of collaborative as compared with competitive strategies in achieving cost control and value for money gains in health services. However, more work is needed to establish the appropriateness of lower laboratory expenditure by linking test requests to diagnosis.

Budgets↗
PubMed1996

The development of independent practice associations and related groups in New Zealand.

AIMS: Independent practice associations (IPAs) have become an important feature of New Zealand's primary care system in the past two years and now represent nearly 60% of general practitioners. This survey was undertaken to document this important development. To determine the extent of the development of IPAs, their goals and barriers to achieving these goals, their policies, financing and contracting development. METHODS: Questionnaire sent to 42 IPAs and related groups in October 1994 with a supplementary questionnaire in April 1995. RESULTS: There were 34 responses, representing the views of 1263 general practitioners. Most important goals were "achieving better health outcomes for patients", "making better use of primary care resources" and "improving the health of the community you serve". Significant barriers to achieving these goals were "lack of time" and "lack of clear RHA policies". There was little support for financial risk sharing or for members personally retaining savings from budget holding. Although there had been significant progress with budget holding considerable frustration was expressed about contracting relationships with RHAs. CONCLUSION: The survey shows that general practitioners are seeing IPAs as ways of achieving professional goals, better quality health care and improving health status outcomes rather than as a means of personal gain. However, protecting and advancing the status of general practice was also important. IPAs expect to move progressively into both budget holding and managed care with the gradual assumption of secondary care services purchasing. This has important implications for the future of RHAs including the need for them to adopt a more strategic purchasing role.

Attitude of Health Personnel↗
PubMed1996

Lost in the market? A survey of senior public health service managers in New Zealand's 'reforming' health system.

In 1993, New Zealand implemented radical health sector reform, separating purchaser from provider and creating a competitive market. This paper reports on a 1994 survey of senior managers' perceptions of how well public health services were adapting to this more commercial environment. An initial questionnaire to chief executive officers of Crown health enterprises, the main providers of public health, as well as secondary treatment services, was followed by a telephone survey of managers of public health services. Chief executives expressed generally positive views about the importance of public health, especially health promotion, within their organisations. Public health managers indicated a wide range of negative and positive views about the new system. They were concerned especially about service fragmentation, diminished information-sharing and decreased collaboration, especially with Maori and general practice providers. Questions were raised about the compatibility of competition with the need for collaboration in public health. The major issue was the inefficient, costly, conflicting and fragmented purchasing arrangements for public health. Managers wanted united systems and fewer purchasers. More positive views were expressed on an improved focus on outputs and clearer directions, and none wanted to return to the former era of an entirely separate system for public health services. The abolition of the Public Health Commission during 1995 should lead to increased integration of purchasing and policy making, but important questions remain about the place of public health services, especially in their links with primary care.

Administrative Personnel↗