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PubMed1996

Ischemic heart disease in patients with end-stage renal disease.

Prevention and treatment of cardiovascular disease and, in particular, ischemic heart disease (IHD) in an increasingly elderly and diabetic population of patients with end-stage renal disease (ESRD) pose a challenge to all members of the renal failure treatment program. The patient described herein presents such a challenge, illustrating risk factors for IHD, the dilemma of performing surgery given his age and comorbid conditions, and the impact of IHD on his quality of life and capacity to function independently. The coordinated efforts of the nephrologist, cardiologist, cardiac surgeon, rehabilitation specialist, nutritionist, primary nurse, and social worker all contributed to a successful intervention.

Aged↗
PubMedDate not supplied

The Division of Nursing and its relationship to nurse practitioner education.

Nurses provide a large part of health care in the United States. Increasingly, among rural and underserved populations, urban and rural NPs and NMWs are taking the place of physicians who choose to specialize and to practice in metropolitan areas. Nurse practitioners and NMWs are well qualified to provide primary care for those with acute and chronic medical conditions, and to provide maternity care to the 95% of women whose pregnancies are normal and do not require specialist care by obstetricians. Since 1965, the DN, through its grant programs, has contributed to increasing the accessibility of health care in this country by helping to increase the supply of nurses in all specialties and improving the quality of graduates and undergraduates in nursing education. In the past 25 years, NPs and NMWs have proven their capability and worth. Federal support has helped to make these invaluable contributions possible.

Financing, Government↗
PubMed1981

The status of hospital discharge data in Denmark, Scotland, West Germany, and the United States.

This section has surveyed characteristics of the health service systems in Denmark, Scotland, West Germany, and the United States. Certain characteristics in each country are likely to increase hospital utilization. In the United States the characteristics include economic incentives to physicians and patients for hospital use and the high percent of physicians in specialty practices. In Denmark the high proportion of hospital-based physicians may increase hospital use. In Scotland the use of capitation to pay office-based physicians and the absence of a nursing home system probably increase hospital use, and in West Germany the large number of physicians per population and the lack of sufficient alternative facilities for long-term care are likely to increase hospital use. On the other hand, each health services system has some characteristics that should decrease hospital use: for instance, the large number of alternative facilities for long-term care in the United States, the well-established programs for home care in Denmark and Scotland, and the small percent of physicians who are specialists in West Germany. Further research is needed to understand the interactions of these factors and the effects they have on hospital use. Increased understanding of the effects of health services system characteristics should result in more useful comparisons of hospital utilization statistics.

Adolescent↗
PubMed1998

Physician supply and medical education in California. A comparison with national trends.

Concerns have been voiced about an impending oversupply of physicians in the United States. Do these concerns also apply to California, a state with many unique demographic characteristics? We examined trends in physician supply and medical education in California and the United States between 1980 and 1995 to better inform the formulation of workforce policies appropriate to the state's requirements for physicians. We found that similar to the United States, California has more than an ample supply of physicians in the aggregate, but too many specialists, too few underrepresented racial/ethnic minority physicians, and poor distribution of physicians across the state. However, recent growth in the supply of practicing physicians and resident physicians per capita in California has been much less dramatic than in the country overall. The state's unusually high rate of population growth has enabled California, unlike the United States as a whole, to absorb large increases in the number of practicing physicians and residents during 1980 to 1995 without substantially increasing the physician-to-population ratio. Due to a projected slowing of the state's rate of population growth, the supply of physicians per capita in the state will begin to rise steeply in coming years unless the state implements prompt reductions in the production of specialists. An immediate 25% reduction in specialist residency positions would be necessary to bring the state's supply of practicing specialists in line with projected physician requirements for the state by 2020. We conclude that major changes will be required if the state's residency programs and medical schools are to produce the number and mix of physicians the state requires. California's medical schools and residency programs will need to act in concert with federal and state government to develop effective policies to address the imbalance between physician supply and state requirements.

California↗
PubMed2002

[Free choice of doctors - an international comparison].

The focus of this international comparison concerning the issue of free choice among primary care physicians and specialists is to learn from experiences in other countries. Two different types of health care systems are analysed: state-administered health systems such as in Finland and Great Britain or competition-based systems such as in Switzerland and the USA. In the countries outlined mentioned and other OECD nations (Organisation for Economic Co-Operation and Development) not described in this study, several restrictions of free choice among physicians can be observed. Restrictions are to be found when changing the general practitioner as well as in first contact to specialists. Both limitations do not seem to have a significant effect on the level of satisfaction of the population with health care in general. From an international perspective free choice of doctors seems to be an exception in health systems.

Cross-Cultural Comparison↗
PubMed1996

Gastroenterology workforce modeling.

OBJECTIVE: To examine the current supply and distribution of gastroenterologists and project future supply under various scenarios to provide a paradigm for workforce reform. DESIGN: An analysis of current practices and distribution of gastroenterologists and a demographic model, using the 1992 gastroenterology workforce as a baseline. MAIN OUTCOME MEASURE: Comparison of current supply, distribution, and practice profiles with past data and future projections, using analyses of data from the 1993 Area Resource File, 1992 Medicare Part B file, age- and sex-specific death and retirement rates from the Bureau of Health Professions, managed care staffing patterns, the National Survey of Internal Medicine Manpower, and the Bureau of the Census. RESULTS: Rapid growth in the number of US gastroenterologists has resulted in a gastroenterologist-to-population ratio double that used on average by health maintenance organizations. In addition, the work profile of gastroenterologists is shared significantly by primary care physicians and other specialists, with the exception of a few specific and uncommon procedures. CONCLUSIONS: Empirical evidence suggests that, even in the absence of detailed models to describe the desired supply/need balance for gastroenterology, the US health care system and clinicians may benefit from a reduction in gastroenterology training programs. The Gastroenterology Leadership Council endorsed a goal of 25% to 50% reduction in trainee numbers over 5 years, and recent National Resident Matching Program data indicate that a voluntary downsizing process is in full force. This study illustrates a paradigm for workforce planning that could be useful for other medical specialties.

Demography↗
PubMed1998

Compliance with national asthma management guidelines and specialty care: a health maintenance organization experience.

BACKGROUND: To improve asthma disease management, the National Asthma Education Program (NAEP) Expert Panel published Guidelines for the Diagnosis and Management of Asthma in 1991. OBJECTIVES: To compare the current status of asthma disease management among patients in a large health maintenance organization with the NAEP guidelines and to identify the factors that may be associated with medical care (eg, emergency department visits and hospital admissions) and adherence to the guidelines. METHODS: Analyses of 1996 survey data from 5580 members with asthma (age range, 14 to 65 years) covered by a major health maintenance organization in California (Health Net). RESULTS: In general, adherence to NAEP guidelines was poor. Seventy-two percent of respondents with severe asthma reported having a steroid inhaler, and of those, only 54% used it daily. Only 26% of respondents reported having a peak flowmeter, and of those, only 16% used it daily. Age (older), duration of asthma (longer), increasing current severity of disease, and treatment by an asthma specialist correlated with daily use of inhaled steroids. Ethnicity (African American and Hispanic) correlated negatively with inhaled steroid use but positively with emergency department visits and hospital admissions for asthma. Increasing age and treatment by an asthma specialist were also identified as common factors significantly related to the daily use of a peak flowmeter and, interestingly, to overuse of beta2-agonist metered-dose inhalers. CONCLUSIONS: Although the NAEP guidelines were published 7 years ago, compliance with the guidelines was low. It was especially poor for use of preventive medication and routine peak-flow measurement. Furthermore, the results showed that asthma specialists provided more thorough care than did primary care physicians in treating patients with asthma. Combining the results of the regression analyses revealed that some of the variation in rates of emergency department visits and hospitalizations among some subpopulations can be explained by the underuse of preventive medication. This study serves the goal of documenting the quality of care and services currently provided to patients with asthma through a large health maintenance organization and provides baseline information that can be used to design and assess effective population-based asthma disease management intervention programs.

Adolescent↗
PubMed2006

Epidemiological and clinical investigations among employees in a former herbicide production process.

OBJECTIVES: To evaluate cancer incidence among employees assigned to a benzothiadiazin herbicide production facility between 1974 and 1984. METHODS: Retrospective cohort study including 185 employees who had worked at least 3 months in the facility. Cancers were identified by review of occupational medical records and interview. Standardized incidence ratios (SIRs) were computed using comparison data provided by the Saarland Cancer Registry. Separately, a medical examination including sonography of the prostate and thyroid and PSA testing was offered to all cohort members including retirees. RESULTS: Between 1975 and 2002, 12 cancers were observed compared with 10.3 expected cases (SIR 1.2; 95% confidence interval 0.6-2.0). Cancer types (including two prostate, two colon and one rectal cancer) were distributed unremarkably with no clustering of rare cancers. Medical screening and subsequent specialist referrals led to detection of three prostate cancers among 117 participants in the screening examination. CONCLUSIONS: Because of the limited study power, a link between former employment in this herbicide production process and the occurrence of cancer cannot be ruled out with confidence, although the observed incidence and distribution of cancers in this small cohort may be consistent with that expected in the general population. Detection of three prostate cancers via the examination program is also consistent with the experience of cancer screening programs that include PSA testing. Enhanced screening for prostate cancer among men over age 50 can lead to detection of cancers at earlier ages than would otherwise be the case. This likelihood needs to be planned for and addressed in communications with the study population prior to undertaking such initiatives.

Adult↗
PubMedDate not supplied

[Factors related with the family physician work's effectiveness and efficiency: a Delphi study in the province of Alicante].

OBJECTIVE: [corrected] To detect factors that more directly restrict effectiveness and efficiency of the family physician's work in the health center. Made proposals for change which will contribute to increase this efficiency and effectiveness. METHOD AND PARTICIPANTS: Consensus method by Delphi technique. Thirty experts, from different settings of the National Health System at the province of Alicante, were requested for participate in this study: 15 health center co-ordinators, 7 directors of district primary care services and 8 chairmen of internal medicine hospital services. Twenty-four experts maintained their participation in all phases of the project, that means 80% of participation. RESULTS: The factors identified with a larger consensus (supported by at least 83% of the participants) were: difficulties in the relationship and communication between primary and secondary care levels; lack of incentives or motivation in manpower policy; vertical health programs not realistic and not well co-ordinated; a society each time more medicalized; deficiencies in the makeup of the general practitioners patients listś; political influences in management; excessive bureaucracy on consultations; deficiencies in continuing medical education; lack of prefixed aims and previously set criteria of standards; different training and involvement levels among professionals; limited access to diagnostic tests and a limited health education level among the population. The solutions proposed with a larger consensus (supported by at least 92% of the participants) were: to improve and increase communication between primary and secondary care levels; to makeup the patient list of every general practitioner and to adjust the staff of the health centers according to sociodemographic population variables and professional duties (practice, management, teaching, research,.); to design programs of continuing medical education with obligatory attendance for professionals; to incentive and to motivate professionals; to professionalize and depoliticize management; reduction of unnecessary bureaucracy on consultations by computing some tasks; to establish guidelines in practice; to introduce the Individual Health Card; self-management in health centers; to increase the primary care capacity in solving health problems; freedom of choice of the specialist consultant by the general practitioner; to release the access for the general practitioners to certain diagnostic tests; to improve certain social services and to increase the time that health center co-ordinators devote to managerial tasks. CONCLUSIONS: Most of the problems identified and the solutions proposed were linked either with organisational or managerial factors or with human resources management. The essences of the new primary care model are not questioned. Other Spanish publications which investigated the opinion of health professional as well, have identified similar problems and proposed similar solutions. This coincidence and the high degree of agreement reached by the participants in designing problems and in proposing solutions, may indicate that factors that most restrict the effectiveness and the efficiency of the family physicians work in health centers are clearly explained and it is necessary to deal with the solutions resolutely.

Delphi Technique↗
PubMed1977

A comprehensive, interdisciplinary approach to the care of the institutionalized person with epilepsy.

This report summarizes the experience of a comprehensive, interdisciplinary pilot program for improved care of institutionalized persons with epilepsy. From a hospital population of nearly 3,000 persons with diseases of the nervous system, virtually all having varying degrees of retardation, 892 persons were identified as epileptic and classified by seizure frequency: 13% uncontrolled, 24% partially controlled, and 63% controlled. These three categories were similar in respect to levels of retardation and functional disability. The project personnel consisted of a full-time nurse specialist in epilepsy, a part-time health resource analyst, and neurological consultants. Effects on health status were identified by comparing demographic and health data collected during the project. The typical patient was an adult epileptic, functioning at a severely to profoundly retarded level and institutionalized for over 15 years. A significant reduction in anticonvulsant toxicity was observed. A 48% decrease in episodes of status epilepticus and a 73% decrease in the number of seizure-related deaths were demonstrated. During the second year, 23% of the uncontrolled group, representing all retardation levels, became seizure free. In addition to improved care, an effective model for dealing with institutionalized epileptics is proposed.

Adolescent↗
PubMed2003

Evaluation of the effectiveness of short-term smoking cessation treatment in patients of the Pulmonary Department, Medical University of Lublin.

From August to December 2001 antinicotine program was performed in the Pulmonary Department of the Medical University of Lublin in order to achieve smoking cessation of hospitalized patients, their families and other people coming to the ambulatory during the "open door" days. The usefulness of the smoker's registration in a specialist ambulatory and effectiveness of specialist advice was analyzed. Three hundred ninety persons were examined and given advice. One hundred thirty-four patients (34.4%) were included in the study during hospitalization, 256 (65.5%) during open door action and from patients' families. Fifty-eight (14.9%) persons had Zyban prescribed, 23 (5.9%) nicotine replacement medications. 183 persons came for control visit (46.9%). One hundred and one subjects resist nonsmoking within the month after first visit. In all of them CO concentration in the expired air was normal. This made patients' declaration more objective. Consciousness of tobacco smoking harmfulness and activities taken to quit smoking seem to rise among the Lublin region population. Accessibility of spirometric tests in the screening diagnosis of COPD, one of the main tobacco-related diseases, rises as well. A specialist plays the main role in motivating the patient to smoking cessation. He shows the patient benefits of such an activity during diagnostic and therapeutic process, keeps essential control and supports psychologically. The family doctor has to play a similar role. There is considerable relative effectiveness of short-term antinicotine treatment. Hospitalization favors resisting smoking, especially when the hospital is a tobacco smoke free zone.

Counseling↗
PubMed2005

Management and treatment of eating disorders in an Italian region.

OBJECTIVE: Eating disorders (ED) are an outstanding health problem in western countries, and bear significant mortality, e.g. anorexia nervosa (AN), and morbidity. The Liguria Region Health Department set up a study with the support of a number of specialists to investigate the number and characteristics of patients referred to institutions, how patients were managed, and the healthcare facilities and personnel involved. METHODS: The retrospective study required that all regional institutions, except two, involved in the treatment of ED during the year 2001 filled out a special questionnaire. RESULTS: Twenty-one institutions (n=19 public, n=2 private) followed 1,220 patients with ED in the mentioned year. The prevalence of such disorders was 6 fold higher in females (1,054 F, 166 M; age range 12-32 years). Bulimia nervosa (BN) proved to be the disorder category most frequently observed (prevalence 59%) followed by AN (26%, p<0.0001) and ED not otherwise specified (EDNOS) (15%, p<0.0001). Most (approximately 90%) of these patients were managed in outpatient settings, and a multidisciplinary team approach was used in fewer than 20% of cases. Hospitalization (complete or partial) was required in 10.5% of patients: 7.1% for mental disturbances and 3.4% for severe malnutrition/electrolyte abnormalities. Fewer than one fourth of patients was admitted to two specialty units (one public and one private) for inpatients in our region with ED. Treatment provided in these centers included a specific nutritional rehabilitation program and psychologic/psychiatric care. Patients more severely underweight underwent nasogastric or parenteral feeding whenever deemed clinically appropriate. The grade of knowledge of ED by general practitioners/pediatricians and their links with trained centers were poor. CONCLUSIONS: Although our data were obtained from a selected population, thus preventing epidemiological conclusions, they show that ED are a significant health concern in our region, with BN representing the most common disorder diagnosed in the different settings (general or specialized medical practices). Overall, the prevalence of such disorders was assessed as six fold higher in females than in males. The emerging issues to be improved are: i) poor level of communication among different specialists and subsequent scanty use of a multidisciplinary team approach in the management of ED ii) insufficient use of guidelines for the management of such disorders iii) paucity of specialty institutions for inpatients with ED iv) inadequate knowledge of the problem by primary care physicians and the community, and poor links with the healthcare institutions that might help.

Adolescent↗
PubMed2006

Needs assessment and review of services for people with inherited metabolic disease in the United Kingdom.

Patients with inherited metabolic diseases need to be viewed as a specialist care group because of the range of expertise required for their diagnosis and management. In the UK, professional concerns have been expressed that existing services would struggle to meet needs resulting from new diagnostic and screening techniques, new treatments and increased survival. This needs assessment and service review was therefore undertaken at the request of the Joint Committee on Medical Genetics, guided by a national multidisciplinary stakeholder group. All 24 specialist centres identified in the UK provided evidence for the review. Approximately 10 000 patients are known to services and their annual number of referrals is increasing. Possible shortfalls in the number of patients attending specialist services were estimated for the UK as a whole by extrapolating the results from the region with the most comprehensive service and comparing this with known patient numbers. This analysis suggests that a further 5600 children and 3300 adults are not looked after by specialist services or have been lost to follow-up. The comprehensiveness of services was assessed using a new scoring system for clinical and organizational criteria. There are major regional disparities in the comprehensiveness of service provision across the country, with some regions having little or no specialist service. Unmet need will increase as a result of new diagnostic technologies, more effective treatments and new neonatal screening programmes; specialist services need to be developed and expanded to provide a comprehensive and more equitable service to the UK population.

Adult↗
PubMed2006

Disease management programs for heart failure: not just for the 'sick' heart failure population.

The development of disease management programs has been a major advance in heart failure care, bringing about significant improvements for the heart failure population, with reduction in readmission, better use of guideline therapy and improved survival. However, at present, the majority of such programs focus their attention only on the sicker segment of this population, with little application of this important service to the broader heart failure population, where potentially benefits may be even more impressive. This has led to an imbalance in the care of patients with heart failure, where aspects of management such as regular structured review and education are preferentially given to the group at the later stages of the natural history of the syndrome. This paper argues for a far wider application of the disease management program concept in heart failure care so as to bring the benefits of specialist care, patient education and follow-up to patients at an earlier stage in the natural history of heart failure.

Diffusion of Innovation↗
PubMed1993

The geographical distribution of psychiatrists in Canada: unmet needs and remedial strategies.

Many efforts are underway to rationalize the process of manpower planning in psychiatry. A wide variation in the geographic distribution of psychiatrists remains. A multidimensional assessment of the needs of a population is recommended, based on the epidemiology of mental disorders, professional and institutional needs, consumer estimates, and the requirements of subgroups. Counting the number of vacant positions for psychiatrists can be misleading. Professional norms for the optimal access of a population to psychiatric services and standards for the quantity and/or quality of services provided need to be developed. Potential outcome measures are suggested, along with a three-tiered system of estimating geographic needs. Deterrent factors to an optimal geographic distribution of most professionals are reviewed, along with factors specific to our residency training programs. In the short term, the benefits and limitations of recruiting foreign-trained psychiatrists are compared with those of recruiting Canadian specialists. Complementary long term strategies include the provision of financial incentives, optimal working conditions, relevant training and maintenance of competence issues, and community support.

Canada↗
PubMed2004

[Reducing maternal mortality in developing countries: theory and practice].

Chiefs of state attending the Millennium Summit (2000) set a goal of reducing maternal mortality by 75% before 2015. Based on knowledge of the epidemiology of maternal mortality/morbidity and on growing experience in the field, the international community defined a relatively low-cost program of evidence-based initiatives. However implementation of that program has been stymied by the reality that increasing geographical accessibility to a full range of quality emergency obstetric care of quality will require large investments of money and time. Increasing financial accessibility remains difficult given the low standard of living of populations and budget cutbacks by national governments. The problems facing women and health workers are mostly overlooked by public health policy. There is need for a multi-disciplinary approach with equal participation of specialists in public health, gyneco-obstetrics, anthropology, health care economics, political science and social and community mobilization.

Adult↗
PubMed1993

The present and future role of the consultant physician with an interest in infection. Council of the British Society for the Study of Infection.

The Council of the British Society for the Study of Infection (BSSI) has considered the present and future role of the Consultant Physician with an interest in infection. The BSSI is anxious to set standards and improve the quality of care delivered to patients with infection; to give advice on the prevention and management of infection and to provide such services economically to assist Health Managers in the purchase of infection-related medical services appropriate to the needs of the community they serve. New approaches to the care of infected patients are reviewed where the Clinical Specialist, Microbiologist and Consultant in Communicable Disease Control (CCDC)--in Scotland, Consultant in Public Health Medicine (CPHM)--work together in a team. As the U.K. moves closer to its European partners in 1992, it seems timely for each specialty to make a clear statement about its training programme and the requirements expected of a fully trained Consultant in each discipline. Comparisons between the ratio of Consultants with a special interest in infection and the population are made, where known, between U.K. and other European countries. A model job description for the U.K. clinical specialist is therefore being made available, the present inadequate numbers of consultants are stated and recommendations made to expand urgently the number of Consultant Physicians with an interest in infection.

Consultants↗