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PubMed1999

Electronic medical record in the intensive care unit.

The EMR in the ICU has the utility of providing the necessary information to make sound clinical decisions for critically ill patients. For it to be optimized, the EMR must be more than just what is being replicated in the written record or merely a documentation tool; it must add value that supports and enhances clinical decision support. The EMR is too expensive a tool just to be a computer designed to ease documentation and retrieve data faster. Gardner and Huff have suggested that the EMR must answer three questions: Why, What, and So What. The "Why" is relatively easy to answer, but the "What" data to use so that the information is meaningful to a provider and the "So What" are more difficult to answer. Provided one can qualitatively assess "What" information is important for a health care provider, then "So What" becomes an important objective in the empirical quantification of the benefits that the EMR provides. It is clear that to analyze some of the outcomes that health care delivery provides, one needs some mechanism to automate the information at the point of care, particularly now that the regulatory agencies are requiring it. Given the fact that there is no single integrated computerized patient record, this becomes the daunting task for the next century. Making it easier for health care providers to interact with the system and providing them with instantaneous feedback that changes their medical decision so they can deliver better care (clinical pathways, clinical practice guidelines) will be the task required of the next generation of CISs.

Computer Systems↗

PubMedDate not supplied

The strategic role of health informatics in integrated delivery systems.

Having accurate measures and high-quality health information is critically important for all providers today. Integrated delivery systems are faced with increasing demands for numerous redundant, sometimes conflicting, performance measurement and reporting data from managed care customers, regulators, and accreditors. When implemented independently within each organizational subunit, these measurement systems are costly and difficult to manage. Centralization of all measurement services can maximize the productivity of the costly resources required to deliver them and can achieve efficiencies, cost savings, and a better balance between internal and external resources while collecting information that is of a higher quality for managerial and clinical decision making.

Capital Expenditures↗

PubMed1995

Rationing health care: the political perspective.

The politics of rationing are messy and treacherous. As long as rationing remained implicit, politicians were shielded from the impact of decisions about who to treat and who not to treat. Explicit rationing changes all this by making the process of reaching choices more visible. However, implicit rationing may actually be a better way of dealing with difficult and complex issues. There is, nevertheless, scope for improving the process and making it more open and accountable. While efforts to terminate ineffective treatments are welcome and overdue, they are not a substitute for rationing. Finally, while politicians are being called upon to set national priorities and guidelines for rationing care, there is resistance to doing so when the decisions are so context specific and can only be made effectively at a micro level.

Decision Making↗

PubMed2005

[Information system in primary health care].

The Croatian Ministry of Health started a health care system computerization project aimed at strengthening the collaboration among health care institutions, expert groups and individual health care providers. A tender for informatic system for Primary Health Care (PHC) general practice, pediatrics and gynecology, a vital prerequisite for project realization, has now been closed. Some important reasons for undertaking the project include rationalization of drug utilization, savings through a reduced use of specialists, consultants and hospitalization, then achievement of better cooperation, work distribution, result linking, data quality improvement (by standardization), and ensuring proper information-based decision making. Keeping non-standardized and thus difficult to process data takes too much time of the PHC team time. Since, however, a vast amount of data are collected on only a few indicators, some important information may remain uncovered. Although decisions made by health authorities should rely on evidence and processed information, the authorities spend most of the time working with raw data from which their decisions ultimately derive. The Informatic Technology (IT) in PHC is expected to enable a different approach. PHC teams should be relieved from the tedious task of data gathering and the authorities enabled to work with the information rather than data. The Informatics Communication Technology (ICT) system consists of three parts: hardware (5000 personal computers for work over the Internet), operative system with basic software (editor, etc.), and PHC software for PHC teams. At the national level (National Public Health Informatics System), a software platform will be built for data collection, analysis and distribution. This data collection will be based on the International Classification of Primary Care (ICPC-2) standard to ensure the utilization of medical records and quality assessment. The system permits bi-directional data exchange between a central database and sources at different levels, across the spectrum from basic PHC teams to local authorities. This will enable data collection control, comparisons with national averages and prompt distribution of information over the Internet. The investment into IT is a strategic imperative having no alternative. A cost/benefit analysis has shown its operation in the PHC system to return the investment in two years. As defined according to the Project priorities (with measurable objectives), the use of new technologies will be introduced by stages.

Croatia↗

PubMed2001

Who wants to know if their care is rationed? Views of citizens and service informants.

OBJECTIVE: To explore the views of citizens and service informants about whether they would want to know about any rationing of their own health care. DESIGN: In-depth interviews using a semistructured schedule. Data were analysed using the methods of constant comparison. SETTING AND PARTICIPANTS: Citizens and service informants. MAIN VARIABLES STUDIED: Issues around health care rationing were explored within the context of the United Kingdom health care system. RESULTS: The views of citizens and service informants were very similar in terms of whether they, personally, wanted to know about any rationing of their own care, with the vast majority wanting to be given this information. Informants were also similar in terms of their reasons for wanting to know about rationing: to be given a 'good explanation' to enable them to judge whether the decision made had been correct; and to enable them to change the decision if necessary, either through protest or payment. Many informants suggested that they would indeed be likely to react either by challenging the decision or by paying for care. CONCLUSIONS: The findings suggest that policies to be open with people about the rationing of care would be welcomed, but also indicate that if protest follows such openness, it may be difficult for the health service to cope with greater explicitness. Further research is needed among patient groups actually facing this situation.

Adult↗

PubMed1994

Gender inequalities of health in the Third World.

This paper examines gender inequalities of health in Third World Countries. Health hazards are present at every stage of a woman's life cycle. Health problems which pose the greatest hardship to women in these countries include: reproductive health problems, excess female mortality in childhood, violence against girls and women, occupational and environmental hazards, and cervical and breast cancer. Many of these lead to maternal mortality which was the most focussed upon indicator of women's health in the literature. Gender inequalities of health originate in the traditional society where definitions of health status and traditional medical practices all reflect the subordinate social status of women. Gender inequalities in health are manifested in traditional medical practices which attribute women's illnesses to behavioral lapses by women; differential access to and utilization of modern healthcare services by women and girls, including maternal care, general healthcare, family planning and safe abortion services. Reasons for gender inequalities in health include--emphasis on women's childbearing roles resulting in early and excessive childbearing; sex preference manifested in discrimination against female children in health and general care; women's workloads which not only expose them to health hazards but also make it difficult for them to take time off for healthcare; lack of autonomy by women leading to lack of decision-making power and access to independent income; early marriage which exposes women to the complications of early and excessive childbearing. Gender inequality in health is one of the social dimensions in which gender inequality is manifested in Third World societies. Strategies to eradicate gender inequalities in health must therefore involve efforts to improve the status of women.

Developing Countries↗

PubMed1996

A comparison of three techniques for rapid model development: an application in patient risk-stratification.

Accurately risk-stratifying patients is a key component of health care outcomes assessment. And, many health care organizations increasingly are relying upon automated means for assistance in making patient risk-stratification decisions. Unfortunately, the process of outcome model development, as it is currently practiced, is both time consuming and difficult. We investigated the relative abilities of three modeling techniques (logistic regression, artificial neural network (ANN), and Bayesian) to rapidly develop models for risk-stratifying patients. Our results demonstrated that all three modeling techniques perform equally well in certain situations. However, the Bayesian model with conditional independence had the best overall performance. Unfortunately, none of the models were able to achieve the degree of accuracy which would be required in a medical setting.

APACHE↗

PubMed2005

Dilemmas in decision-making about resuscitation--a focus group study of older people.

Cardiopulmonary resuscitation (CPR) may be used by default on patients suffering a cardiac arrest in hospital in the UK unless there is an order that specifies otherwise in the patient's notes. Guidelines recommend that the decision involves competent and willing patients or, in the case of incapacitation, their families. In practice, patient autonomy is often compromised. Ideally, discussion of preferences for end-of-life care should take place prior to hospitalisation. The majority of research on this topic has been conducted on hospitalised patients, so little is known about the views of older, but healthy, people about resuscitation decision-making. The present study was designed to address this gap. A series of eight focus groups involving a total of 48 participants over the age of 65 was conducted to explore people's views about the factors guiding resuscitation decision-making. A qualitative analysis, which emphasised the dilemmatic nature of resuscitation decision-making, identified two broad thematic dilemmas that subsumed six specific themes which contribute to resolving the dilemmas: quality of life (medical condition, mental versus physical incapacity, age and ageing, and burden), and the involvement of others (doctors and families) versus loss of autonomy. The dilemma underlying quality of life is that an acceptable quality of life after CPR cannot be assured. The dilemma underlying the involvement of others is that individual autonomy may be lost. The themes and subthemes provide the basis for guiding these difficult discussions in advance of serious illness.

Advance Care Planning↗

PubMed1996

Supporting patient autonomy: decision making in home care.

This study examines the policies and procedures that home health care agencies have developed to handle the incapacitated patient and life-sustaining treatment decisions. Data collected from a survey of 154 home health care agency directors and interviews with 92 local agency staff (including nurses and social workers) and 67 patients confirmed that directors, staff, and patients agree that patients are informed about their legal rights. When asked about specific rights, fewer patients were aware of their right to execute an advance directive, and even fewer patients had actually executed one. Only 67 percent of agencies reported having existing policies on advance directives and life-sustaining treatment decisions, whereas 41.5 percent had policies on how to handle the patient with questionable decision-making capacity. Consistent policies are needed for social workers, nurses, and other staff to handle such difficult ethical dilemmas. A review of specific agency policies is presented with recommendations for future policy changes and development.

Advance Directives↗

PubMed2003

A population-based survey of complementary and alternative medicine use in men recently diagnosed with prostate cancer.

PURPOSE: To determine prevalence and patterns of use of complementary and alternative medicine (CAM) among men recently diagnosed with prostate cancer. STUDY DESIGN: Men, diagnosed with prostate cancer over a 10-month period in British Columbia, Canada, were randomly selected to obtain a population-based sample. METHODS: Surveys, addressing patient demographics, types of CAM therapies, and CAM information resources utilized, reasons for use, and disclosure to physician(s), were mailed to 1108 men newly diagnosed with prostate cancer. A 42% response rate was obtained. RESULTS: Thirty-nine percent of patients used CAM therapies with the most common being herbal supplements (saw palmetto), vitamins (vitamin E), and minerals (selenium). The most common reasons given for choosing to use CAM therapies were to (1) boost the immune system and (2) prevent recurrence. The majority of men (58%) had told their physician(s) about their CAM use, but few utilized either their family physician (15%) or their oncologist (7%) as sources of CAM information. CAM users most commonly consulted friends or family (39%) or the Internet (19%) for information about CAM. CAM users were more likely than nonusers to delay (9%) or decline (4%) conventional treatment. Respondents who had never used CAM had typically never thought about it or did not have enough information about the treatments. CONCLUSIONS: More than one third of recently diagnosed prostate cancer patients utilize some form of CAM therapy, and the majority disclose their use to their physician(s). However, they tend to rely on anecdotal information for their CAM decision making. Dissemination of reliable CAM information is one key to helping men navigate this difficult arena.

Adult↗

PubMed1999

Optimizing hospital-based home care for dying cancer patients: a population-based study.

Health-related quality of life (HRQL) is difficult to define and measure. It is a generic term that includes concepts such as physical health, life satisfaction, psychological well-being and self-integrity. Realizing and appreciating the importance of HRQL is crucial for physicians if they are to be in a position to offer appropriate suggestions in assisting patients and their families in the decision-making process regarding cancer treatment and terminal care. In order to determine whether Greek physicians take into consideration HRQL when assessing different therapeutic options, we conducted a postal survey. A total of 1500 Greek physicians (internists, oncologists and anaesthesiologists) were asked to complete a questionnaire. We received replies from 1280 (85%). In summary, we found that Greek physicians: (1) have already started taking HRQL into consideration when reviewing their therapeutic options; (2) increasingly include HRQL in research studies as an outcome measure; (3) do not yet have thoroughly sufficient training in the holistic care of cancer patients and their families; (4) mostly do not have the opportunity to work in interdisciplinary therapeutic teams where they can exchange ideas and consider different aspects of alternative therapeutic methods. It is concluded that HRQL has already been introduced as an important determinant of therapeutic choices in cancer care in Greece. However, efforts need to be made to allow HRQL to enjoy its appropriate place in cancer care.

Adult↗

PubMed1998

The meaning of DNR status: oncology nurses' experiences with patients and families.

Patients, providers, and families are increasingly involved in end-of-life decisions (advance directives, health care proxy, do-not-resuscitate [DNR] status consents). These decisions can be complex processes whereby the participants in the process must come to terms with often painful and difficult decisions. The role perception of the nurse in end-of-life decision making is not well delineated. This chapter explores the results of a study that addresses the question, "What are the experiences of oncology nurses as they interact with patients and/or family members during the process of patients/families signing DNR consents. The grounded theory method of data collection and analysis was used to explore this question. The results of the study indicate that central to the process of consenting to DNR status is the degree of shared understanding about the meaning of DNR status among participants and the conflict that can occur when meanings are not shared. A model is presented that illustrates the connections between the meanings of DNR (patient, family, and provider) and congruence and conflict in the DNR consent process. Strategies are discussed that facilitate prevention or resolution of conflict in the DNR status decision-making process. Strategies used by the nurse to facilitate decision making by patient and families include communicating with, caring for, educating, advocating for, and collaborating with patients, families, and other providers.

Adult↗

PubMed2005

Monitoring political decision-making and its impact in Austria.

The range of services provided by the Austrian health care system has been greatly extended over the last few decades. The accompanying measures for long-term care bring the situation closer to the ideal concept of a 'seamless web' between primary, secondary and tertiary care. Due to the expansion in services it has become increasingly difficult to ensure the balance between the financing and degree of usage of the services. The reiterated political aim has been to achieve balanced financing via legally fixed social health insurance (SHI) contributions and taxation. A steadily expanding part is contributed by the private sector. In the 1980s, measures for SHI expenditure containment were implemented; in 1997 a new hospital financing system based on flat rates was introduced. In order to guarantee hospital financing, the historical financing shares of the SHI for the hospitals were introduced in the form of valorised global budgets. The contradictory incentives arising from the flat rates and global budgets lead hospitals to shift services to the primary and tertiary care sector, causing additional expenditure for SHI. Currently, attempts are being made to secure the financing by increasing the SHI contribution rates and patients' co-payments.

Austria↗

PubMed1984

Assessment of obstetric high risk factors in a developing country.

The detection of women with obstetric high-risk factors is now recognized as a major aim of antenatal care, especially in developing countries, and those factors most important in Papua New Guinea obstetric practice have been identified by a study of maternal deaths. The present study aimed to assess the value of the detection of these factors by comparing the outcomes of pregnancies with and without high risk factors. Home, health centre and hospital deliveries in two districts of Enga Province in the Papua New Guinea Highlands were studied. Of the total 2225 deliveries, 74% took place at home, the proximity of a health centre appearing to be a major determinant in the choice between home or supervised institutional delivery. Fifty-three per cent of women had at least one high risk factor, and 92% of these factors were historical. Eighty-two per cent of women had an uncomplicated normal delivery, while post-partum haemorrhage was the commonest complication, occurring in 7.6% of deliveries. This complication also caused all 4 maternal deaths. There was good correlation between delivery complications and the presence of high-risk factors, 70% of complications occurring in at-risk pregnancies. It is concluded that the detection of high-risk factors in pregnancy is very worthwhile. But, as a separate study has shown, the rate of detection antenatally could be improved, and until more health centres are constructed it will probably prove difficult to persuade all those at high risk to deliver under supervision.

Developing Countries↗

PubMed2003

Market-focused management: a model for US academic health centers.

This paper describes managed care, competition and high health care costs and reductions in funding as the major market forces that affect US academic health centers. As academic health centers continue to preserve their missions of providing patient care, educating and training health professionals and conducting research, they are negatively impacted by these market changes, thus, resulting in increased expenses and lowered revenue. A key component to surviving in difficult times is market-focused management. This paper develops a model to show the path of senior level management teams in their decision making. Through the performance of essential managerial roles, senior level managers are responsible for strategies that result in the long-term viability and growth of academic health centers.

Academic Medical Centers↗

PubMed2005

[Market and ageing].

Ageing can be defined as growth of the proportion of elderly people in the population, but also as a group of transformations in life cycles: older age at time of first job, marriage, birth of first child, early retirement, longer life expectancy, active retirement, greater number of dependent persons. The economic impact of the ageing population has been extensively studied from the perspective of the social security fund. In France and in most developed countries, population ageing has considerably destabilized social accounting creating a gap between a system thought out after WWII and the present social environment. The current response of social security system to elderly person's needs is considered inadequate. There are however other consequences of ageing. It is important to measure the upheaval caused by longer life expectancy and changing life stages on all markets. Three kinds of markets are involved in different ways: job market, services market for the elderly and all goods market for seniors and golden aged. Many studies have focused on the links between economic production and physiological ageing. The traditional organisation of working conditions stresses working intensity over experience, young workers'capabilities over than those of older workers. The link between age and the job market can also be analyzed by considering supply and demand for employment for workers over 50. Another question is the workforce shortage forecasted in some sectors (health and social sectors in particular) and the role of immigration. Growth in the supply of long-term care will require restructuring of the sector's logistics and financing. Certain trends are appearing: government authorities are reducing their supply of services, private production is increasing, public financing is being maintained, and individual contributions are growing while the role of insurance has remained stagnant. A qualitative analysis of the markets also shows heterogeneous workers situations and status creating difficult consequences for management decision making. The best-known impact of ageing on markets is the development of the senior and golden-age markets (technical help, accessibility, improved housing, leisure activities and training...) The particularities of these markets and their development are extensively studied, particularly questions related to new technologies.

Age Factors↗

PubMedDate not supplied

The quality of life associated with prophylactic treatments for women with BRCA1/2 mutations.

PURPOSE: This study was conducted to obtain and compare the preferences assigned to cancer states and prevention measures by women who had breast cancer, were at high risk for breast cancer, or had neither condition. PATIENTS AND METHODS: We administered a time trade-off questionnaire to 21 breast cancer patients, 28 women with a personal history of multiple breast biopsies or a family history of breast cancer, and 135 women without these conditions (the reference group). We stratified the reference group into two groups aged 20 to 32 years and 33 to 50 years, respectively. RESULTS: All four groups assigned higher preference to breast cancer than to ovarian cancer. Both reference groups preferred using a tamoxifen-like drug to having mastectomy or oophorectomy for cancer prevention; the high-risk and breast cancer groups did not. None of the four groups had a preference between prophylactic mastectomy and breast cancer. All the groups were willing to subtract more years from their life expectancy to protect offspring from genetic risk than to protect themselves. Reference group members in the 33- to 50-year age range had lower mean ratings than the breast cancer group for almost all the health states, and breast cancer patients were less willing than other respondents to trade time for health. Most of these differences were not statistically significant. The high-risk group was similar to the older reference group in time trade-off ratings. DISCUSSION: The time trade-off-based preferences of healthy women may be used to predict the treatment preferences of women with BRCA1/2 mutations. Obtaining healthy women's ratings of treatment outcomes may help health care policy makers envision the consequences of the difficult choices that high-risk women face.

Adult↗

PubMed2001

Biomedical ethics and the withdrawal of advanced life support.

It is common for health care providers to deal with the complex and difficult issue of withdrawing advanced life support. The patient is always the key source of authority in these decisions. The most important ingredient in end-of-life decision making is effective communication. It is important to try to ascertain what the patient thought about quality-of-life values before surrogate decisions can be made on the patient's behalf. The concepts of beneficence, nonmaleficence, autonomy, and justice are the foundation of ethical decision making. Numerous legal precedents have laid the groundwork for end-of-life decision making. Most state courts have supported withholding and withdrawing life support from patients who will not regain a reasonable quality of life. The recent Patient Self-Determination Act encourages patients to fill out advance directives that state their desires. When continued intensive care is futile, advanced life support should be withdrawn. However, a narrow definition of futility in this situation is the key, since the concept of futility could lead to inappropriate decisions. It is best to consider a situation futile when the patient is terminally ill, the condition is irreversible, and death is imminent. During the withdrawal of advanced life support, terminal or rapid weaning is preferable to extubation. Combinations of opiates, benzodiazepines, and other agents help provide comfort to patients who are suffering.

Communication↗