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PubMed1995

California physicians' willingness to care for the poor.

Although generalist physicians appear to be more likely than specialists to provide care for poor adult patients, they may still perceive financial and nonfinancial barriers to caring for these patients. We studied generalist physicians' attitudes toward caring for poor patients using focus groups and used the results to design a survey that tested the generalizability of the focus group findings. The focus groups included a total of 24 physicians in 4 California communities; the survey was administered to a random sample of 177 California general internists, family physicians, and general practitioners. The response rate was 70%. Of respondents, 77% accepted new patients with private insurance; 31% accepted new Medicaid patients, and 43% accepted new uninsured patients. Nonwhite physicians were more likely to care for uninsured and Medicaid patients than were white physicians. In addition to reimbursement, nonfinancial factors played an important role in physicians' decisions not to care for Medicaid or uninsured patients. The perception of an increased risk of being sued was cited by 57% of physicians as important in the decision not to care for Medicaid patients and by 49% for uninsured patients. Patient characteristics such as psychosocial problems, being ungrateful for care, and noncompliance were also important. Poor reimbursement was cited by 88% of physicians as an important reason not to care for Medicaid patients and by 77% for uninsured patients. Policy changes such as universal health insurance coverage and increasing the supply of generalist physicians may not adequately improve access to care unless accompanied by changes that address generalist physicians' financial and nonfinancial concerns about providing care for poor patients.

Adult↗

PubMed1995

No breathing room in the anesthesia turf battle.

Anesthesiologists and nurse anesthetists have always jostled each other for work, but managed care and policy changes have brought tensions to a boil. Is the anesthesia battle a harbinger of the future?

Anesthesia Department, Hospital↗

PubMedDate not supplied

Family nursing in community-oriented primary health care.

Renowned for its innovative approach to community health promotion and the key role of the nurse in treatment, prevention, teaching and research, the Philip and Sally Lown Hadassah Community Health Centre in Jerusalem is a model where the nurse is a member of a comprehensive multidisciplinary team that comprises family and paediatric physicians, epidemiologists, psychologist, statistician, social worker, health educator, health recorder, dietician and other public health specialists. As such, the nurse actively participates in the planning, implementation and evaluation of all new programmes, improvements and policy changes. Below, how the nurse works as a team member in the community centre.

Community Health Centers↗

PubMed1994

Morphine use and adverse effects in a neonatal intensive care unit.

Prescribing patterns and appropriateness of morphine use in a neonatal intensive care unit (NICU) were evaluated in a concurrent drug-use evaluation (DUE). Data were collected for 99 infants who received morphine over a six-month period. Patient charts were reviewed to collect the following data: patient's age, weight, dosage schedule, concurrent sedatives, ventilatory status, whether adequacy of analgesia was documented, and descriptions of adverse drug reactions (ADRs). The physicians' orders were reviewed to determine whether NICU morphine dosage guidelines were followed and whether the indication for use was noted. Seven ADRs occurred in six of the patients; three of the ADRs occurred after ophthalmic cryosurgery. Indications for use were noted in 79 of 285 physician orders (27.7%). The adequacy of sedation or analgesia was documented on 60 of the 360 patient days (16.7%). The DUE results prompted several changes: physicians were asked to select indications from a list in the computerized order-entry system, an analgesia or sedation assessment scale was added to nursing flow sheets, and endotracheal intubation became a requirement before ophthalmic cryosurgery. A follow-up DUE showed nearly complete compliance with the new guidelines for morphine use and a reduction in the number of adverse reactions to morphine. A DUE prompted policy changes that improved documentation of indications for and efficacy of morphine use and reduced adverse reactions to the drug in an NICU.

Analgesia↗

PubMed1994

The role of human rights and personal dignity in the rehabilitation of chronic psychiatric patients. A rural therapeutic community in Yanbian, Jilin.

In 1983 the branch hospital of the Yanbian Community Psychiatric Hospital, a rural residential centre for 120 chronic psychiatric patients who have no means of financial support, adopted a new treatment philosophy that emphasised psychosocial rehabilitation and made the protection of patients' human rights and respect for their personal dignity the central organising principles for the hospital's treatment programme. From being a boarding facility for chronic psychiatric patients, the hospital became a thriving community. Comparison of the status of the 81 continuously resident schizophrenic patients before and after the policy change showed that (a) the proportion who actively participated in agricultural labour increased from 10% in 1982 to 38% in 1990; (b) the proportion who worked at non-agricultural jobs increased from 7% in 1982 to 22% in 1990; and (c) their mean yearly income increased from 1.67 Rmb in 1982 to 246.70 Rmb in 1990. Moreover, the number of successful suicides among all the patients in the hospital dropped from 13 in 1975-1982 to 1 in 1983-1990. We conclude that the success of psychiatric rehabilitation programmes depends on the extent to which they address the core issues of personal dignity and basic human rights.

China↗

PubMedDate not supplied

The economic impact of AIDS: a challenge for nursing.

Estimates to determine the cost of financing AIDS care have been uncertain. Current policies governing private insurance as well as Medicaid/Medicare eligibility have created a number of barriers for people with AIDS (PWA). As the number of AIDS cases increase, nursing will play a crucial role in developing necessary policy changes to improve access to care, contain costs, and continue to provide much needed care to PWA.

Acquired Immunodeficiency Syndrome↗

PubMed1994

Using Medicaid claims data to evaluate a large physician fee increase.

OBJECTIVE: This study demonstrates the use of Medicaid claims data in order to evaluate a threefold fee increase in physician fees for deliveries ($265 to $795), which the Maryland Medicaid program implemented in 1986. DATA SOURCES AND STUDY SETTING: The study used Maryland Medicaid claims data for years of service 1985-1988, and was done at the Maryland Department of Health and Mental Hygiene with the help of a Robert Wood Johnson, Health Care Financing and Organization (HCFO) grant. STUDY DESIGN: Overall, our design is that of a pre-test, post-test with multiple observation points both before and after the fee increase. We measured participation in three ways, corresponding to three different units of analysis. With the county-quarter year as unit of analysis, we followed a panel of providers over 16 quarters for each county in the state to determine changes in the number of delivering providers. With the individual provider as the unit of analysis, we identified effects on their Medicaid caseload between years that may have been influenced by the fee increase. Finally, we looked at continuously enrolled Medicaid women who delivered to determine the effects of the fee increase on site and volume of prenatal care. DATA COLLECTION/EXTRACTION METHODS: Analytic files for each unit of analysis were compiled from previously extracted Medicaid claims files using standard statistical software packages. PRINCIPAL FINDINGS: Using techniques described, we were able to get an in-depth picture of overall responsiveness to the intervention. We found a moderate influence of the fee increase on overall participation, less than what we would have predicted. CONCLUSIONS: Administrative data can be used to construct efficient, yet sophisticated evaluations of major policy changes. Findings from our evaluation suggest a moderate effect of the fee increase on overall participation. However, raising fees to the level of private third party payers does not in itself guarantee equal access to private physician health care for Medicaid mothers.

Adolescent↗

PubMed1994

Confronting the use of placebos for pain.

What do you do when a physician's order conflicts with your role as patient advocate? Here's how one nurse initiated a policy change that put an end to the unethical use of placebos.

Chest Pain↗

PubMed1994

Impact of the 1990 contract for general practitioners on night visiting.

BACKGROUND: The 1990 contract for general practitioners extended the hours of eligibility for night visiting claims by 25% and introduced financial incentives to discourage the use of deputizing services. AIM: This study set out to examine the impact of these contract changes on the rate and pattern of night visiting. METHOD: Family health services authority data were used to compare trends in night visiting before and after the introduction of the new contract. Rates were calculated separately for those authorities which might be expected to have a high rate of visiting because of their demographic structure and those that might be expected to have a high rate because of their socioeconomic composition, thus separating out these two sets of factors combined in the Jarman index. RESULTS: Rates of night visiting increased by 33% between 1989 and 1990 while the proportion of visits made by deputies fell by 19%. These changes could not simply be explained either by the extension of eligible hours or the success of financial incentives in changing behaviour in the appropriate direction. It was found that the effect of the new contract was to increase visiting most in family health services authorities with a high proportion of elderly people living alone, that is, where demand would be expected to be higher. In previous years there had been little variation in visiting rates between authorities with a high proportion of those aged 65 years and over living alone and those with a low proportion. The effect of the contract was also to increase rates of visiting most in affluent authorities, that is, where demand would be predicted to be lower. This again marked a sharp break with trends in previous years in that the gap between the high rates in the deprived family health services authorities and lower rates in the most affluent authorities narrowed. CONCLUSION: The 1990 contract achieved the government's policy aims of promoting night visiting by principals and discouraging the use of deputies in its first year. However, the finding that doctors responded more to demand from elderly people and affluent people than from deprived people presents a challenge both for analysis and for policy. It underlines the importance of disaggregating the Jarman index when examining the impact of policy change on local populations and suggests that general practitioners in the most deprived family health services authorities may lack the capacity or the incentive to respond to the changes introduced in the 1990 contract.

Adolescent↗

PubMed1994

Oral health and nutrition.

The relationships between oral health conditions, dietary practices and nutritional status, and general health status in the older American are complex, with many interrelating factors. Just as inadequate nutrition can affect oral health, poor oral health status affects food choices and, thus, nutritional status. It is clearly essential that the primary care practitioner and/or screening health professionals always include an evaluation of oral status in assessment of an elderly person. Effective care for the elderly dental patient requires knowledge about the disease of aging and the impact of those diseases on oral health and nutrition, pharmacology and drug interactions and their impact on oral health status, the biology of aging including sensory changes, the relationship of general medicine and systemic diseases, and psychology and sociology. The attitudes of empathy and understanding, caring and compassion, respect and a positive attitude toward the older patient, and flexibility in treatment planning are also critical elements. The interdisciplinary team of physicians, nurses, nutrition professionals, dentists, and social service professionals must all work together to ensure that good oral health status and adequate nutrition are maintained in older Americans. Recognizing and treating oral health and nutrition problems are important in improving the health and quality of life for the elderly population. Research that can provide more answers to health care problems in this growing group; educating professionals with respect to the relationships between oral health and nutrition; and public policy changes with regard to provision and funding of nutrition services, especially when provided by registered and/or licensed nutrition professionals, contribute to improving the health and quality of life for elders.

Aged↗

PubMedDate not supplied

The Medicaid eligibility expansions for pregnant women: evaluating the strength of state implementation efforts.

Surveys of state Medicaid agencies and maternal and child health programs were conducted in late 1991 and in 1992 to evaluate the extent to which states carried out a series of federal policy changes intended to improve low-income women's access to prenatal care. The results show a great deal of variability in the aggressiveness with which states implemented these Medicaid eligibility expansions. Overall, North Carolina, Maryland, Massachusetts, New York and Arkansas moved most aggressively to carry out the expansions; Kansas, Nebraska, South Dakota, North Dakota and Wyoming were ranked least aggressive. States with relatively high levels of poor birth outcomes or low-birth-weight deliveries prior to the Medicaid expansions were generally more likely than other states to have undertaken reforms intended to increase the number of women eligible for assistance and ease their enrollment. In addition, expansion efforts were greater in states where the federal government paid more of the cost of caring for Medicaid recipients.

Eligibility Determination↗

PubMed1993

The status of women in dermatology.

In the near future, almost one-third of all American physicians will be women. Many of these women will be pressured by the needs to balance parental/family and professional responsibilities during the formative stages of their careers. Recommendations for medical school policy changes that recognize these pressures are made.

Adult↗

PubMedDate not supplied

Public attitudes about cigarette smoking: results from the 1990 Smoking Activity Volunteer Executed Survey.

The 1990 Smoking Activity Volunteer Executed Survey collected information on a wide range of policy-relevant issues concerning public attitudes about cigarette smoking. These issues include cigarette taxes, advertising restrictions, minors' access to tobacco products, school-based prevention, and exposure to environmental tobacco smoke in workplaces and public areas. Survey data were collected during the spring and summer months of 1990 from random samples of adults from Arizona, Michigan, Pennsylvania, and Texas. Telephone interviews were conducted by trained American Cancer Society volunteers using standardized questionnaires. Cluster sampling techniques, interviewer training and supervision, and data collection procedures were designed in conformity with the methodology of the Behavioral Risk Factor Surveillance System of the Centers for Disease Control and Prevention. Smoking prevalence ranged from a low of approximately 20 percent in Texas to a high of 31 percent in Michigan. Between 60 and 69 percent of the respondents in the four States, including between 44 and 71 percent of current smokers, believe tobacco should be classified as a drug. Around 65 percent of the respondents would support an extra tax on tobacco to finance public campaigns against smoking, and between 61 percent and 69 percent favor banning cigarette advertising in the print media and on billboards. More than 82 percent of the respondents believe that stronger laws should be enacted to prevent the sale of tobacco products to minors, and more than 86 percent believe that existing laws should be better enforced. Current smokers were only slightly less likely than were former and never smokers to indicate support of policy changes to prevent minors'access to tobacco products; the two groups had somewhat more disagreement in the amount of support for the other smoking control policies.Finally, although between 62 and 88 percent of working respondents reported the presence of smoking restrictions at their workplace, between 26 and 48 percent still reported being bothered by smoking at work.These study findings suggest that existing smoking control policies are not restrictive enough or are inadequately enforced. The study documents strong public concern in the four States about the in adequacy of current policies and support for the enactment of stronger legislation to control smoking behavior.

Adolescent↗

PubMed1993

HIV, breast-feeding and under-5 mortality: modelling the impact of policy decisions for or against breast-feeding.

A computer model was developed to assess the impact on under-5 child mortality of breast-feeding practices in developing countries in the context of HIV infection. The model was used to estimate the effect on mortality of cessation of breast-feeding among mothers HIV-positive and mothers HIV-negative at birth, for both urban and rural settings. Using parameter values for a hypothetical East African country, cessation of breast-feeding in urban areas was predicted to result in increases in under-5 mortality of 108% for children of mothers HIV-negative at birth, and 27% for those HIV-positive at birth, with slightly larger increases in rural areas, suggesting that breast-feeding should continue to be promoted. A sensitivity analysis was conducted to identify critical values of key variables for which a review of policies encouraging breast-feeding is indicated. This showed that, even under extreme assumptions, cessation of breast-feeding among mothers HIV-negative at birth (but at risk of acquiring HIV during the lactation period) would increase under-5 mortality. For mothers HIV-positive at birth, the key variables are the additional risk of vertical transmission attributable to breast-feeding, the under-5 mortality rate (U5MR) in breast-fed children, and the relative risk of mortality in non-breast-fed compared to breast-fed children. Depending on the values of these key variables, there may be some urban populations with low U5MR in which the positive and negative effects on under-5 mortality of a policy change are finely balanced. However, no change in policy should be made in these areas until more precise information is available on the key variables, and the many adverse consequences of such a change have been fully explored.

Breast Feeding↗

PubMed1993

[Smoking habits among pregnant women in Norway--suggestions for intervention].

Multiple surveys have shown that approximately 35 percent of women in Norway are daily cigarette consumers during their pregnancies. Smoking is the single most important risk factor in pregnancy leading to excessive rates of low birth weight, prenatal neonatal and infant mortality, sudden infant death syndrome and learning problems in school. Norway provides a decent prenatal care program free of charge to all pregnant women. But efforts to reduce smoking have been inadequate. A multilevel strategy including a media campaign, the policy changes recommended in the Action Plan "Smokefree Norway by the year 2000" and a standardized intervention program using generally available resources is suggested as a possible way to reduce the problem throughout the country.

Female↗

PubMed1993

Impact of the Catastrophic Coverage Act and new coverage guidelines on Medicare skilled nursing facility use.

The promulgation of new coverage guidelines and provisions of the 1988 Medicare Catastrophic Coverage Act indicated that Medicare's role in financing nursing home care could expand greatly. This paper presents a facility-level analysis addressing how the policy changes affected the payer mix of subgroups of Medicare-certified skilled nursing facilities (SNFs). Our analysis found that the new policies increased participation of nursing homes in the Medicare SNF program and suggested that the policies expanded both access to the Medicare SNF benefit and the role of public financing for nursing home care. Greater responsiveness to the policies was observed among proprietary SNFs and among those with more beds.

Catastrophic Illness↗

PubMedDate not supplied

Regulation of biotechnology products in the global pharmaceutical market: the case of the European community and the United States.

Biotechnology represents an opportunity for innovative products, new markets, or capital investments, depending on one's perspective. A primary consideration in regulating this industry is to ensure that innovation is not stifled yet the public is protected from potentially unsafe or ineffective products. We compared the regulatory requirements and procedures for obtaining marketing approval for biotechnology products in the European Community (EC) and the United States and identified key concerns of the biotechnology industry regarding the regulatory aspects of these products. The methodology consisted of a secondary literature review and mail survey. Biotechnology products are approved faster in the EC than the US. Both the EC and the US use advisory or expert committees in their respective approval procedures, although the EC does so more regularly. Market exclusivity provisions for biotechnology products range from 6 to 10 years in the EC compared with 7 years for "orphan" biotechnology products in the US. Regulatory affairs managers of the biotechnology industry were most concerned about application review time periods, communication with regulatory agencies, consistency in implementing regulations, and public policy changes. These concerns provide insight into the deficiencies that exist in regulatory processes and are valuable in identifying problems and implementing improvements.

Biotechnology↗

PubMed1995

Assessing the outcome of making it easier for patients to change general practitioner: practice characteristics associated with patient movements.

BACKGROUND: The government white paper, Promoting better health, suggested that primary health care services should be made more responsive to patient needs and that competition, brought about by the freer movement of patients between practices, could act as a mechanism for improving the quality of the services provided. Policy changes reflecting these aims were introduced with the 1990 contract for general practitioners. AIM: A study was carried out to estimate the volume of patient movement between practices not attributable to a patient's change of address or to a major change in the practice they had left, and to investigate which practice characteristics patients moved towards and which they moved away from when changing general practitioner. METHOD: Data on 2617 patient movements during June 1991 were collected from five family health services authorities. These patient movements were analysed in relation to data on practice characteristics obtained from family health services authority records. RESULTS: The estimated volume of movement of patients between practices was small (1.6% of the registered population per year). The majority of movements were between group practices; a quarter of the movements recorded were to single-handed general practitioners. However, the ratio of the number of movements from group practices to single-handed general practitioners compared with those from single-handed general practitioners to group practices was 1.37 (95% confidence interval 1.19 to 1.57). In choosing single-handed general practitioners these patients were willing to forgo access to a woman general practitioner, extended services and greater hours of general practitioner availability. Among the subset of movements between group practices, patients were more likely to gain access to a practice nurse, longer surgery hours and a woman general practitioner as a consequence of their move. CONCLUSION: The scale of patient movement observed did not indicate any substantial mechanism by which the new policy of encouraging consumerist behaviour on the part of primary care users could effect desired changes in primary care practice. Among the patient movements observed, the evidence suggests that when choosing a practice potential patients were not deterred by the fact that a practice was single-handed. The public's perception of the factors contributing to a high quality of service may conflict with the official characterization of good practice and high quality services in primary health care.

Adolescent↗