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PubMed2003

A comparison of health insurance in Slovenia and Croatia.

Before Croatia and Slovenia became independent in 1991, they had similar health systems. They have generally taken the same reform path since then, but have also travelled in opposite directions on occasions. Of particular relevance here, both countries established quasi-government agencies to administer a new national scheme of compulsory health insurance in 1993. However, Slovenia's compulsory scheme involved much larger copayments, and a parallel voluntary insurance scheme was created mainly to cover them. In 2002, Croatia increased copayments and introduced a voluntary insurance scheme almost identical to that of Slovenia's. To complete the circle, Slovenia has announced it intends to abandon the use of voluntary insurance for copayments, and reduce the level of copayments for its compulsory scheme. This paper describes and compares the two insurance systems, and I argue that there has been considerable success in difficult circumstances. However, the experiences reinforce aspects of design that seem to be generally relevant: the need to make use of consumers' informed opinions, to recognise and then redress a lack of experience of optional approaches among many of those making decisions about health insurance, to define and apply a rigorous evaluation framework that includes estimating peoples total costs for health care, to emphasise the long term, to identify and ensure there is transparency of vested interests, and to use the financial power of the dominant government insurer to encourage and reward improvements in clinical practice.

Bed Occupancy↗

PubMed1977

Health care cost-containment regulation: prospects and an alternative.

Regulation of the health care system to achieve appropriate containment of overall costs is characterized by Professor Havighurst as requiring public officials to engage, directly or indirectly, in the rationing of medical services. This rationing function is seen by the author as peculiarly difficult for political institutions to perform, given the public's expectations and the symbolic importance of health care. An effort on the part of regulators to shift the rationing burden to providers is detected, as is a trend toward increasingly arbitrary regulation, designed to minimize regulators' confrontations with sensitive issues. Irrationality and ignorance are found to plague regulatory decision making on health-related issues, even though it is the consumer who is usually thought to suffer most from these disabilities. The author argues that consumer choice under some cost constraints is a preferable mechanism for allocating resources because it better reflects individuals' subjective preferences, has a greater capacity for facing trade-offs realistically, and can better contend with professional dominance of the resource allocation process. In view of the unlikelihood of regulation that is both sensitive and effective in containing costs, the author proposes that we rely primarily on consumer incentives to reform the system. A simple change in the tax treatment of health insurance or other health plan premiums, to strengthen consumers' interest in cost containment while also subsidizing needy consumers, is advocated. Steps to improve opportunities for innovation in cost containment by health insurers, HMOs, and other actors are outlined briefly.

Choice Behavior↗

PubMed1998

The delay to thrombolysis: an analysis of hospital and patient characteristics. Quebec Acute Coronary Care Working Group.

OBJECTIVE: To describe the various components of the delay to thrombolytic treatment for patients with acute myocardial infarction (MI) and to identify the hospital and patient characteristics related to these delays. DESIGN: Cohort analysis from a hospital registry of patients receiving thrombolytic treatment. SETTING: Forty acute care hospitals in Quebec. SUBJECTS: All 1357 patients who received thrombolysis between January 1995 and May 1996. MAIN OUTCOME MEASURES: Time from onset of symptoms to arrival at hospital and the various components of the in-hospital delay. RESULTS: The median delay before presentation to hospital was 98 (interquartile range [IR] 56 to 180) minutes and was longer for women (p < 0.001), patients over 65 years of age (p < 0.001) and patients with diabetes mellitus (p < 0.01). The median time from arrival at hospital to thrombolysis was 59 (IR 41 to 89) minutes, the medical decision-making component taking a median of 12 (IR 4 to 27) minutes. Women (p < 0.005), older patients (p < 0.001) and patients with a past history of MI (p < 0.001) had increased in-hospital delays to thrombolysis. Delays were longer in community hospitals (p < 0.05) and low-volume centres (p < 0.01) and when a cardiologist made the decision to administer thrombolysis (p < 0.001). Multivariate analysis showed that increased age (odds ratio 1.5, 95% confidence interval 1.3 to 1.7, p < 0.001) and having the medical decision made by a cardiologist (odds ratio 1.8, 95% confidence interval 1.6 to 2.0, p < 0.001) were independently associated with an increased risk of being in the upper median of in-hospital delays. CONCLUSIONS: Despite certain improvements, there remain substantial delays between symptom onset and the administration of thrombolysis for patients with acute MI. A large part of the delay is due to the hesitation of patients (particularly women, older patients and patients with diabetes) to seek medical attention. Although the median time for medical decision-making appears reasonable, care must be taken to ensure that all patient groups receive timely evaluation and therapy. The delay associated with having the treatment decision made by a cardiologist probably represents a marker for more difficult, complex cases. Methods should be developed to permit specialty consultation, if needed, while minimizing treatment delays. Community and low-volume hospitals may require special attention.

Aged↗

PubMed2006

Consumer decision making in the individual health insurance market.

This paper summarizes the results from a study of consumer decision making in California's individual health insurance market. We conclude that price subsidies will have only modest effects on participation and that efforts to reduce nonprice barriers might be just as effective. We also find that there is substantial pooling in the individual market and that it increases over time because people who become sick can continue coverage without new underwriting. Finally, we show that people prefer more-generous benefits and that it is difficult to induce people in poor health to enroll in high-deductible health plans.

California↗

PubMed2001

Families and nursing home placements: a cross-cultural study.

With the aging of many populations, health care workers and families increasingly find themselves jointly involved in situations involving decisions about nursing home placements. How each approaches such situations is affected by beliefs and assumptions about the role of family members in the care of family members and the decision making process. This paper explores the responses of people from four cultural groups living in Australia (Anglo-Celtic Australian, Chinese, Greek, Lebanese) to a critical incident scenario about a Russian family in Australia faced with such a decision. The responses to this scenario were remarkably similar across the four cultural groups. All saw making such a decision as difficult, but the reasons for the difficulty suggest some interesting cross-cultural distinctions. Some groups viewed care of a family member more in terms of a social and role obligation while others addressed it as a personal responsibility. To not care for elderly parents in the home was accompanied by a sense of guilt among some respondents and a sense of public social shame among others. Ambivalence about nursing homes and placing a family member in a nursing home, culture change and cross-generational differences, and roles and role support were other important themes. The results are consistent with other data analysed in conjunction with the Intercultural Interaction Project. The findings from this research suggests a need to examine more closely the beliefs and assumptions associated with nursing home placements and one way to help students and health professionals to do so.

Journal Article↗

PubMed1999

A critical evaluation of clinical practice guidelines in neonatal medicine: does their use improve quality and lower costs?

Clinical practice guidelines and care pathways have become a focus of quality improvement efforts in Neonatology. Health care administrators believe that using clinical practice parameters reduces health care costs, improves quality of care, and limits malpractice liability. Practice guidelines and surveys of consumer satisfaction have grown in use partly because third-party payers, insurers, and health maintenance organizations, as well as hospital administrators bent on reducing variable costs of care and contracting for capitated care have championed their development, implementation, and monitoring. Overall there is minimal evidence-based medicine to support that neonatal outcomes have benefitted from their implementation, although some studies show affirmative effects in limited populations or in a limited number of centres. For highly autonomous physicians and nurses this standardization of medical decision making may represent a difficult transition into efforts to improve quality, based on evidence-based care, and in some instances into corporate medicine. By realigning the traditional values of patient relationships, including parent involvement, the implementation of guidelines has been fast-tracked in some institutions, without appropriate audit to determine their effectiveness in achieving their goals. However, because guidelines and clinical pathways are here to stay, neonatologists need to think critically about how their content and method of implementation, monitoring and modification may influence medical and nursing teaching and decision making in the future. If guidelines are introduced primarily as a cost savings or containment tool that ignores their impact on the quality of medical care and thereby restricts needed care, then neonatologists must be quick to challenge the potentially damaging and inappropriate use of guidelines and care pathways. Several international efforts are underway to study both the impact of evidence-based guidelines and to determine if they can be imported from one care system into another. Furthermore, there are many medico-legal implications of guideline and clinical pathway implementation that may not favour physicians and other neonatal care practitioners, and leave to hospitals, insurers, and ultimately the courts, decisions regarding evidence-based care. Neonatologists and other practitioners in neonatal care centres should critically analyse the goals of guideline development, implementation and monitoring and should restrict themselves to guideline directed care only at those practices for which there is evidence supporting their implementation and continuous monitoring.

Consumer Behavior↗

PubMed1992

Surveillance for equity in primary health care: policy implications from international experience.

Experience around the world shows that health agencies can promote community-based surveillance for equity to focus low-cost interventions on priority needs. Social inequities which have seemed intractable can be resolved if care responds directly to demonstrated need. The concept of promoting equity as a basic principle of primary health care has an interesting psychological twist. The ethical imperative of equity can strengthen services when linked with the practical management tool of surveillance. Moral conviction in applying this social justice norm can facilitate action which is made efficient by the realism of statistically based methods of surveillance. If international agencies condition their aid on surveillance for equity their assistance will more likely go to those in greatest need. This is a more efficient and effective way of tracking their money than the previous tendency to set up vertical programmes which generally have poor sustainability. Surveillance helps mobilize political will and community participation by providing practical data for local, district and national decision-makers. The many field demonstrations of successful surveillance for equity tend to have been brushed off by development experts who say they are difficult to replicate nationally. The Model County Project in China shows how a systematic extension process can test procedures in experimental areas and adapt them for general implementation. Surveillance can help bureaucracies maintain capacity for flexible and prompt response as decentralization promotes decision-making by local units which are held responsible for meeting equity targets. Surveillance for equity provides a mechanism to ensure such accountability.

Adult↗

PubMed1993

[Autonomy of the patient and the physician in resuscitation situations and in terminal care. The value of advance directives by the patient].

Interactions between the autonomy of the patient and that of the physician (or his professional ethics respectively) in difficult situations, i.e. resuscitation or care in terminal phases of disease, are discussed. In this respect the ethical and legal value of a declaration written and signed by the patient at a time of good health (will) is analyzed.

Advance Directives↗

PubMed1998

The computer based patient record: a strategic issue in process innovation.

Reengineering of the workplace through Information Technology is an important strategic issue for today's hospitals. The computer-based patient record (CPR) is one technology that has the potential to profoundly modify the work routines of the care unit. This study investigates a CPR project aimed at allowing physicians and nurses to work in a completely electronic environment. The focus of our analysis was the patient nursing care process. The rationale behind the introduction of this technology was based on its alleged capability to both enhance quality of care and control costs. This is done by better managing the flow of information within the organization and by introducing mechanisms such as the timeless and spaceless organization of the work place, de-localization, and automation of work processes. The present case study analyzed the implementation of a large CPR project ($45 million U.S.) conducted in four hospitals in joint venture with two computer firms. The computerized system had to be withdrawn because of boycotts from both the medical and nursing personnel. User-resistance was not the problem. Despite its failure, this project was a good opportunity to understand better the intricate complexity of introducing technology in professional work where the usefulness of information is short lived and where it is difficult to predetermine the relevancy of information. Profound misconceptions in achieving a tighter fit (synchronization) between care processes and information processes were the main problems.

Cost Control↗

PubMed1988

Study design for technology assessment: critical issues.

The epidemiological methods have become useful tools for the assessment of the effectiveness and safety of health care technologies. The experimental methods, namely the randomized controlled trials (RCT), give the best evidence of the effect of a technology. However, the ethical issues and the very nature of the intervention under study sometimes make it difficult to carry out an RCT. Therefore, quasi-experimental and non-experimental study designs are also applied. The critical issues concerning these designs are discussed. The results of evaluative studies are of importance for decision-makers in health policy. The measurements of the impact of a medical technology should go beyond a statement of its effectiveness, because the essential outcome of an intervention or programme is the health status and quality of life of the individuals and populations concerned.

Clinical Trials as Topic↗

PubMed1994

Attitudes of critical care medicine professionals concerning distribution of intensive care resources. The Society of Critical Care Medicine Ethics Committee.

OBJECTIVE: To determine critical care practitioners' attitudes about the importance of various factors in decisions to use intensive care, including age, prognosis, quality of life, patient preference, and medical condition. DESIGN: Cohort study. SETTING: The Annual Educational and Scientific Symposium of the Society of Critical Care Medicine. SUBJECTS: Participants at the symposium. RESULTS: A self-administered questionnaire was distributed and 600 (52%) of 1,148 registrants attending the symposium responded. Eighty-four percent of respondents were physicians and 11% were nurses. Physicians were internists (30%), surgeons (24%), pediatricians (22%), and anesthesiologists (19%); 58% were in academic practices. Very few respondents believed that age should be a criterion for limiting intensive care (12%). Quality of life as viewed by the patient, probability of surviving hospitalization, reversibility of the acute disorder, and nature of the chronic disorder were the factors that most respondents considered to be important in decisions to admit to the intensive care unit. The patient's social worth, previous psychiatric history, cost-benefit analysis, and cost to society were the factors most respondents considered of little importance. Over 40% of respondents would admit patients with a chronic vegetative state or a patient with metastatic carcinoma and a superimposed, life-threatening event. CONCLUSIONS: These results suggest that critical care providers, who must occasionally face difficult decisions about how to distribute limited resources among patients with competing needs, were not often inclined, at the time of this survey, to make choices based on estimates of who might benefit most. These critical care physicians' attitudes about triage may not support the optimal use of critical care resources.

Adult↗

PubMed2006

The facilitating role of information provided in genetic counseling for counselees' decisions.

PURPOSE: To investigate genetic counselees' evaluations of the helpfulness of the information they receive in genetic counseling and of their difficulty in making decisions, and to determine correlates of these two outcomes. METHODS: A field study on 108 counselees seeking genetic counseling aimed at arriving at a reproduction-related decision. Prior to counseling, questionnaires measuring individual differences in factors expected to correlate with outcomes were administered. The objective controllability of the information conveyed in counseling was evaluated by counselors. The outcomes--decision difficulty and information helpfulness--were evaluated one month after counseling in a telephone interview. RESULTS: Information about consequences of options and about possible controlling actions were evaluated as most helpful; whether other information was helpful depended on the type of decision to be made. Decision difficulty was unrelated to counselees' evaluations of the helpfulness of the information. Decision difficulty was also unrelated to individual difference variables, but was related to the objective controllability of the information. CONCLUSION: These findings may help develop guidelines for identifying clients prior to counseling for whom making reproduction-related decisions will be difficult, and for tailoring information that will help such clients reach a decision.

Decision Making↗

PubMed2006

When the leader has a group in a difficult situation.

A novice leader can be unnerved when faced with a group that has rigid time constraints and the personal responsibility to ensure group task is accomplished. The leader may become overwhelmed with obstacles that are difficult to control. However, use of careful group leadership strategies can make what seems like a daunting task doable and can allow the group to successfully meet goals and objectives.

Administrative Personnel↗

PubMed1998

Nurses' participation in audit: a regional study.

OBJECTIVES: To find out to what extent nurses were perceived to be participating in audit, to identify factors thought to impede their involvement, and to assess progress towards multidisciplinary audit. RESEARCH DESIGN: Qualitative. METHODS: Focus groups and interviews. PARTICIPANTS: Chairs of audit groups and audit support staff in hospital, community and primary health care and audit leads in health authorities in the North West Region. RESULTS: In total 99 audit leads/support staff in the region participated representing 89% of the primary health care audit groups, 80% of acute hospitals, 73% of community health services, and 59% of purchasers. Many audit groups remain medically dominated despite recent changes to their structure and organisation. The quality of interprofessional relations, the leadership style of the audit chair, and nurses' level of seniority, audit knowledge, and experience influenced whether groups reflected a multidisciplinary, rather than a doctor centred approach. Nurses were perceived to be enthusiastic supporters of audit, although their active participation in the process was considered substantially less than for doctors in acute and community health services. Practice nurses were increasingly being seen as the local audit enthusiasts in primary health care. Reported obstacles to nurses' participation in audit included hierarchical nurse and doctor relationships, lack of commitment from senior doctors and managers, poor organisational links between departments of quality and audit, work load pressures and lack of protected time, availability of practical support, and lack of knowledge and skills. Progress towards multidisciplinary audit was highly variable. The undisciplinary approach to audit was still common, particularly in acute services. Multidisciplinary audit was more successfully established in areas already predisposed towards teamworking or where nurses had high involvement in decision making. Audit support staff were viewed as having a key role in helping teams to adopt a collaborative approach to audit. CONCLUSION: Although nurses were undertaking audit, and some were leading developments in their settings, a range of structural and organisational, interprofessional and intraprofessional factors was still impeding progress. If the ultimate goal of audit is to improve patient care, the obstacles that make it difficult for nurses to contribute actively to the process must be acknowledged and considered.

Clinical Competence↗

PubMed2002

What outcomes matter to patients: a physician-researcher point of view.

BACKGROUND: During the last quarter of the 20th century, it became feasible to measure and take into account the patient's subjective preferences for health states and various outcomes. This has become increasingly relevant in the treatment of cancer, where patients are confronted with a life-threatening illness and may have varied treatment choices and outcomes. OBJECTIVES: To provide a framework for examining the outcomes that matter to patients from a clinician-researcher perspective. Considerations include the heterogeneity of the cancer patient population, the influence of the setting of care on patient outcomes, the range of outcomes that are often considered by patients and researchers, and possible study designs that should be considered to measure outcomes that are important to patients. The outcomes that matter to patients can broadly be classified into disease-focused and patient-focused outcomes. CONCLUSIONS: There are many challenges in the measurement of patient-focused outcomes, including consensus on what are the most important outcomes and the methods for their measurement. In addition, it is often difficult to integrate disease-focused and patient-focused outcomes in the same setting, particularly for use in clinical decision making. We need to develop some key strategies to enhance patient outcomes including (1) emphasis on evidence-based treatments whenever possible, as the best way of improving disease-focused outcomes; (2) the inclusion of patient preferences when different treatment alternatives provide equivalent disease-focused outcomes; and (3) the provision of adequate time for communication about disease-focused and patient-focused outcomes, with emphasis on the training of clinicians to facilitate these discussions.

Adult↗

PubMed1999

When, how, and why of advance directives: tools for the cardiovascular nurse.

In the U.S., cardiovascular disease is the number one cause of death. The chronicity and unpredictable nature of cardiovascular disease will affect thousands of patients and families who are often called upon to make difficult end of life choices. The federal legislation of the Patient Self Determination Act (PSDA) was passed in 1990 and went into affect in December of 1991. The essence of this legislation was to empower the public with the right to make end of life decisions. However, after almost 10 years of implementation there is little evidence of national acceptance by the health care industry as evident in the literature. Likewise, the public demonstrates limited knowledge regarding advance directives. The law applies to all health care facilities that receive any federal reimbursement for services and includes hospitals, nursing homes, home health agencies, and clinics. The PSDA requires health care institutions to establish mechanisms for disseminating information about advance directive, to patients and to designate personnel responsible for discussing advance directives with patients. In this paper, practical and clinical application to the special considerations of the patient and end of life choices will be discussed. A focus on facts, resources, and other information will be presented for the cardiovascular nurse in a variety of health care settings.

Advance Directives↗

PubMed1986

Partial hospitalization. An alternative to inpatient psychiatric hospitalization.

Partial hospitalization programs provide alternatives to traditional inpatient hospitalization. The initial optimism generated by the development of partial hospital programs has been moderated by the realization that it is quite difficult to make changes in mental health care, even though the effectiveness of traditional approaches has not been demonstrated. Research findings about partial hospital programs have provided information that many persons formerly treated as inpatients can be treated in partial hospital programs, probably at an economic savings. Several conceptual models are briefly reviewed for providing direction and rationale to guide thinking, planning, and decision making regarding client care. Continual effort must be given to the development and expansion of useful models and sets of interventions for care directed not only at symptom reduction but toward facilitation of health induction. Partial hospitalization programs have the potential to provide the settings and services to meet this need. Changing times offer nurses new opportunities to consider alternatives for providing psychiatric care. It is a challenge which nurses are well prepared to accept. To ignore the current situation and the needs of clients, families, and communities for these services would be to lose an opportunity for nurses to share a significant role in providing services to psychiatric clients.

Day Care, Medical↗

PubMed1999

Rational decision-making in mental health: the role of systematic reviews.

BACKGROUND: "Systematic reviews" have come to be recognized as the most rigorous method of summarizing confusing and often contradictory primary research in a transparent and reproducible manner. Their greatest impact has been in the summarization of epidemiological literature - particularly that relating to clinical effectiveness. Systematic reviews also have a potential to inform rational decision-making in healthcare policy and to form a component of economic evaluation. AIMS OF THE STUDY: This article aims to introduce the rationale behind systematic reviews and, using examples from mental health, to introduce the strengths and limitations of systematic reviews, particularly in informing mental health policy and economic evaluation. METHODS: Examples are selected from recent controversies surrounding the introduction of new psychiatric drugs (anti-depressants and anti-schizophrenia drugs) and methods of delivering psychiatric care in the community (case management and assertive community treatment). The potential for systematic reviews to (i) produce best estimates of clinical efficacy and effectiveness, (ii) aid economic evaluation and policy decision-making and (iii) highlight gaps in the primary research knowledge base are discussed. Lastly examples are selected from outside mental health to show how systematic reviews have a potential to be explicitly used in economic and health policy evaluation. RESULTS: Systematic reviews produce the best estimates of clinical efficacy, which can form an important component of economic evaluation. Importantly, serious methodological flaws and areas of uncertainty in the primary research literature are identified within an explicit framework. Summary indices of clinical effectiveness can be produced, but it is difficult to produce such summary indices of cost effectiveness by pooling economic data from primary studies. Modelling is commonly used in economic and policy evaluation. Here, systematic reviews can provide the best estimates of effectiveness and, importantly, highlight areas of uncertainty that can be used in "sensitivity analysis". DISCUSSION: Systematic reviews are an important recent methodological advance, the potential for which has only begun to be realized in mental health. This use of systematic reviews is probably most advanced in producing critical summaries of clinical effectiveness data. Systematic reviews cannot produce valid and believable conclusions when the primary research literature is of poor quality. An important function of systematic reviews will be in highlighting this poor quality research which is of little use in mental health decision making. IMPLICATIONS FOR HEALTH PROVISION: Health care provision should be both clinically and cost effective. Systematic reviews are a key component in ensuring that this goal is achieved. IMPLICATIONS FOR HEALTH POLICIES: Systematic reviews have potential to inform health policy. Examples presented show that health policy is often made without due consideration of the research evidence. Systematic reviews can provide robust and believable answers, which can help inform rational decision-making. Importantly, systematic reviews can highlight the need for important primary research and can inform the design of this research such that it provides answers that will help in forming healthcare policy. IMPLICATIONS FOR FURTHER RESEARCH: Systematic reviews should precede costly (and often unnecessary) primary research. Many areas of health policy and practice have yet to be evaluated using systematic review methodology. Methods for the summarization of economic data are methodologically complex and deserve further research

Journal Article↗