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PubMed2005

Participatory research--'challenging the throne without losing your head': an interview with Tony MacCulloch. Interview by Lynne S. Giddings.

Participatory research approaches, though varied methodologically, share a belief in the importance of social action and the involvement of research participants. This article focuses on a modified approach to co-operative inquiry, a participatory methodology predominantly informed by humanistic psychology. It is the thirteenth in a series of articles based on interviews with nursing and midwifery researchers, designed to offer the beginning researcher a first-hand account of the experience of using particular methodologies. After describing briefly some of the varieties of approaches to participatory research and their theoretical underpinnings, the article presents an interview with Tony MacCulloch (RPN; RGN; Dip Couns; MEd) who used a modified form of co-operative inquiry to explore the risks experienced by tertiary educators who challenged oppressive structures in their workplace. It examined their experience of strategies that supported them in the course of voicing their concerns. A secondary purpose was to support educators who sought to further the ideals of transformative education.

Attitude of Health Personnel↗
PubMed1983

Establishing cost centers within libraries of medical centers.

Medical centers that educate students, treat patients, and perform medical research usually adopt accounting methods for separating those functions financially--designating each function as a cost center. Faculty members who participate in more than one of the separately charged activities have their salaries apportioned accordingly. Cost-shared services, such as a computer facility or a power plant, may also be apportioned among the cost centers. Given this approach to accounting, the shared services of the medical center's library should be included in such an apportionment. Whether such is the case, why the matter is of concern, and how such accounting can be performed were recently studied.

Academic Medical Centers↗
PubMed1992

HIV prevention and the two faces of partner notification.

In the cases of medical patients with sexually transmitted diseases (particularly those with the human immunodeficiency virus), two distinct approaches exist to notifying sexual and/or needle-sharing partners of possible risk. Each approach has its own history (including unique practical problems of implementation) and provokes its own ethical dilemmas. The first approach--the moral "duty to warn"--arose out of clinical situations in which a physician knew the identity of a person deemed to be at risk. The second approach--that of contact tracing--emerged from sexually transmitted disease control programs in which the clinician typically did not know the identity of those who might have been exposed. Confusion between the two approaches has led many to mistake processes that are fundamentally voluntary as mandatory and those that respect confidentiality as invasive of privacy. In the context of the AIDS epidemic and the vicissitudes of the two approaches, we describe the complex problems of partner notification and underscore the ethical and political contexts within which policy decisions have been made.

Confidentiality↗
PubMed2003

Future directions for academic practice plans: thoughts on organization and management from Johns Hopkins University and the University of Pennsylvania.

Academic practice plans have been challenged in recent years by increasing pressures for productivity and financial performance. Most practice plans began as relatively loose affiliations among the clinical departments associated with their respective medical schools, and such approaches were adequate in an earlier era. However, this model is not well suited to deal with the current and future challenges that face the practice plans, hospitals, and medical schools that comprise our academic medical centers. The current clinical, financial, and regulatory environment requires highly effective business management, a shared commitment to common goals, and meticulous attention to regulatory compliance. In turn, the organizational structures, daily management, and overall governance of academic practice plans must be revised to address these new expectations. The business, clinical, and academic performance of the individual practices must be aligned to meet the diverse, and sometimes conflicting, needs of the academic health center. Both Johns Hopkins Medicine and the University of Pennsylvania (Penn Medicine) have been addressing these issues independently, but their approaches share many common principles. Among others, these principles include (a) organizational alignment, (b) strong practice plan business management, (c) shared resources and strategies, (d) accountability for performance in each practice based on credible data generated by the practice plan, (e) uniform audit and compliance standards, and (f) application of market strategy principles to assure the right mix of primary and specialist physicians, and appropriate incentive-based compensation for physicians. The application of these approaches at two academic health centers, and the rationale for these approaches, are discussed in detail.

Cost Sharing↗
PubMed1999

Using a mobile robot to study locust collision avoidance responses.

The visual systems of insects perform complex processing using remarkably compact neural circuits, yet these circuits are often studied using simplified stimuli which fail to reveal their behaviour in more complex visual environments. We address this issue by testing models of these circuits in real-world visual environments using a mobile robot. In this paper we focus on the lobula giant movement detector (LGMD) system of the locust which responds selectively to objects which approach the animal on a collision course and is thought to trigger escape behaviours. We show that a neural network model of the LGMD system shares the preference for approaching objects and detects obstacles over a range of speeds. Our results highlight aspects of the basic response properties of the biological system which have important implications for the behavioural role of the LGMD.

Animals↗
PubMed2003

Needle sharing among southern Thai drug injectors.

AIM: To examine factors associated with needle sharing among injecting drug users (IDU) in southern Thailand. DESIGN: Using a cross-sectional survey, 272 active IDU were interviewed about their socio-economic background, needle sharing and drug use patterns at six drug-treatment clinics in southern Thailand. FINDINGS: Ninety-one per cent of IDU gave a past history of ever sharing injecting equipment: of these, 23% currently injected but did not share and 68% still shared. Only 5% of participants knew that bleaching needles could reduce HIV transmission risks. Recent needle sharing was correlated with number of IDU friends (OR 12.23; CI, 5.24-28.51), engaging in illegal jobs (OR 2.74; CI, 1.13-6.67), being unable to use new needles at all times (OR 2.89; CI, 1.17-7.14) and believing that cleaning contaminated shared needles with at least plain water could reduce HIV transmission (OR 3.32; CI, 1.16-6.68). CONCLUSIONS: Our data suggest that AIDS prevention efforts should focus on approaches to reduce needle sharing. Needle exchange programs, HIV counseling and testing and bleach distribution may reduce levels of needle-sharing risks.

Adult↗
PubMed2002

AI and SAR approaches for predicting chemical carcinogenicity: survey and status report.

A wide variety of artificial intelligence (AI) and structure-activity relationship (SAR) approaches have been applied to tackling the general problem of predicting rodent chemical carcinogenicity. Given the diversity of chemical structures and mechanisms relative to this endpoint, the shared challenge of these approaches is to accurately delineate classes of active chemicals representing distinct biological and chemical mechanism domains, and within those classes determine the structural features and properties responsible for modulating activity. In the following discussion, we present a survey of AI and SAR approaches that have been applied to the prediction of rodent carcinogenicity, and discuss these in general terms and in the context of the results of two organized prediction exercises (PTE-1 and PTE-2) sponsored by the US National Cancer Institute/National Toxicology Program. Most models participating in these exercises were successful in identifying major structural-alerting classes of active carcinogens, but failed in modeling the more subtle modifiers to activity within those classes. In addition, methods that incorporated mechanism-based reasoning or biological data along with structural information outperformed models limited to structural information exclusively. Finally, a few recent carcinogenicity-modeling efforts are presented illustrating progress in tackling some aspects of the carcinogenicity prediction problem. The first example, a QSAR model for predicting carcinogenic potency of aromatic amines, illustrates that success is possible within well-represented classes of carcinogens. From the second example, a newly developed FDA/OTR MultiCASE model for predicting the carcinogenicity of pharmaceuticals, we conclude that the definitions of biological activity and nature of chemicals in the training set are important determinants of the predictive success and specificity/sensitivity characteristics of a derived model.

Animals↗
PubMed1979

Sharing in preschool children: Facilitation, stimulus generalization, response generalization, and maintenance.

Three approaches to facilitating verbal and physical sharing and of the generalizability and durability of the behaviors that were trained were investigated. During a free play period, groups of preschool children were taught to share verbally, to share physically, or to share verbally and physically; another group was not trained. Immediately following free play, the children were observed in a different setting. Follow-up was conducted 4 weeks after training ended. Physical sharing that was durable and generalizable resulted only when children were taught to share verbally. Increases in physical sharing produced by training children to share only physically were not durable and did not generalize. Training both verbal and physical sharing produced results with a magnitude slightly greater than teaching just verbal sharing. Despite a lack of special programming, some of the treatment effects generalized to another setting and were maintained during the Follow-up. There was response generalization of the effects of training verbal sharing to physical sharing but not vice versa. Problems with the concept of response class, a methodological suggestion for studying response generalization, and possibilities concerning why generalization and maintenance occurred without specific programming are discussed.

Journal Article↗
PubMed2002

Provider-patient roles in chronic disease management.

Health care provider-patient role relationships can influence patient satisfaction, adherence to treatment, and health outcomes positively. Existing models of role relationships reflect one of three approaches to clinical management--paternalism, consumerism, or shared decision making. These models may or may not reflect the reality of chronic disease management in clinical practice. To characterize the nature of chronic disease management from the perspectives of primary care providers, we asked four nurse practitioners and four internists to describe the roles they saw for themselves and for their patients. A qualitative approach using a descriptive mode supported the formulation of a narrative description of these roles. The roles reflected a paternalistic approach to chronic disease management. The shared decision making approach supported in the literature was not evident. This finding is important for health professional education and practice.

Chronic Disease↗
PubMed2003

Straight talk new approaches in healthcare. The outpatient market: protect important market share.

Hospitals are facing competition from myriad freestanding players in the outpatient market. It's a fight hospitals can't afford to lose because they often use outpatient profits to cover losses in other service lines. Indeed about 60% of the average hospital's operating margin depends on outpatient revenues. In this session of Straight Talk, we examine how hospitals can build and finance outpatient services with physicians, increasing their competitiveness in increasingly competitive markets.

Capital Financing↗
PubMed2000

Change management of shared and local versions of health-care terminologies.

Local sites that adopt a shared health-care terminology for computer-based systems have local needs that prompt the local-terminology maintainers to make changes to the local version of the shared terminology. If the local site is motivated to conform to the shared terminology, then the burden lies with the local site to manage its own changes and to incorporate the changes of the shared version at periodic intervals. We call this process synchronization. We survey current approaches that address problems of sharing and local modification, and we present the CONCORDIA model, which supports carefully controlled divergence of a local version from a shared terminology. CONCORDIA provides the underlying design and methodology for the implementation of a synchronization-support tool.

Humans↗
PubMed1995

Research on field-based services: models for reform in the delivery of mental health care to populations with complex clinical problems.

OBJECTIVE: Clinical services for psychiatrically impaired populations have only recently been studied with scientifically valid designs to explore innovations in structure, accessibility, and financing. Health systems reform in the United States has provided the impetus for better defining clinically effective and cost-sensitive models for mental health services. This article reviews assertive community treatment, used for adults with severe mental illnesses, and multisystemic therapy, used for adolescents with serious emotional disturbances, as examples of service system innovations that have been studied with controlled clinical trial designs and have demonstrated efficacy in treating difficult and costly clinical populations. METHOD: The authors reviewed the published controlled clinical trials of assertive community treatment and multisystemic therapy, focusing on the clinical and administrative elements that distinguish them from traditional service systems. RESULTS: A qualitative assessment of these two approaches suggests that they share common elements, with important implications for mental health policy. Specifically, the use of an ecological model of behavior applied to mental health patients is critical to both systems. In addition, therapeutic principles emphasizing pragmatic (outcome-oriented) treatment approaches, home-based interventions, and individualized goals are key elements of their success. Most important, both systems embody a therapeutic philosophy demanding therapist accountability, in which personnel are rewarded for clinical outcomes and therapeutic innovation rather than for following a prescribed plan. CONCLUSIONS: As empirically tested approaches, assertive community treatment and multisystemic therapy provide a scientific foundation for continued reform and serve to illustrate critical elements in designing new community treatment initiatives for behavioral as well as medical conditions.

Adolescent↗
PubMed2003

Approaches to pharmacy benefit management and the impact of consumer cost sharing.

BACKGROUND: Numerous mechanisms have been introduced to deliver prescription drug benefits while controlling pharmaceutical costs. An understanding of the most prominent mechanisms of benefit management is an important step in determining the most effective approach to take in future years. OBJECTIVES: The aims of this review were to illustrate the mechanisms by which managed care has attempted to efficiently and equitably deliver pharmacy benefits and to discuss the impact of such programs, including consumer cost sharing. METHODS: A review of the literature was conducted using the PreMedline and MEDLINE databases from the years 1966 to 2002, reference lists from relevant articles, and online sources, including news releases, conference materials, and pharmacy benefit management reports. RESULTS: Numerous pharmacy benefit management tools and their impact on utilization, expenditures, and health outcomes are reviewed, including disease state management; utilization management (ie, quantity limitations and prior authorization); drug utilization review; formulary management (ie, open and closed); delivery systems (ie, retail and mail order); and mechanisms for implementing consumer cost sharing (ie, generic incentives, multitiered copayments, and co-insurance). Although there is some evidence to suggest that certain benefit management tools have been successful in reducing health plan expenditures, a more thorough investigation of their potential unintended consequences is needed. CONCLUSIONS: Implementing adequate levels of consumer cost sharing is necessary if employers and health plans are to continue offering prescription drug benefits. It is important to remember, however, that quality health care cannot be forfeited for the sake of short-term cost savings.

Community Participation↗
PubMed1995

Constructing clinical applications: the GALEN approach.

A common problem for developers of clinical applications is coping with the diversity of medical language. Medical language as it is used all over the world varies widely, while the referents for these words stay essentially the same. Software developers must reconcile this diversity with the practical necessity of producing applications that are usable in a variety of hospitals, while ensuring that information can be shared between applications. Existing approaches center around coding and classification schemes, but these approaches must be supplemented by a range of sophisticated terminological services in order for the language barriers to be overcome. To address this, the GALEN project is developing an application called the Terminology Server to provide such a range of terminological services (e.g., conceptual and multilingual services). The software is built upon a re-usable core model of medical terminology. This paper reports on the development of a clinical application called the SCUI (Structured Clinical User Interface) which draws on these GALEN technologies and illustrates an innovative approach to the construction of future clinical applications. The SCUI was specifically developed and tested in the context of infectious diseases to satisfy the demands made by the medical intensive care unit on the Geneva Hospital's microbiology laboratory.

Clinical Laboratory Information Systems↗
PubMed2005

Identification of polymorphisms explaining a linkage signal: application to the GAW14 simulated data.

We applied three approaches for the identification of polymorphisms explaining the linkage evidence to the Genetic Analysis Workshop 14 simulated data: 1) the genotype-IBD sharing test (GIST); 2) an approach suggested by Horikawa and colleagues; and 3) the homozygote sharing test (HST). These tests were compared with a family-based association test. Two linked regions with highest nonparametric linkage scores were selected to apply these methods. In the first region, Horikawa's method identified the most SNPs within the region containing the disease susceptibility locus, while HST performed best in the second region. However, Horikawa's method also had the most type I errors. These methods show potential as additional tools to complement family-based association tests for the identification of disease susceptibility variants.

Chromosomes, Human, Pair 1↗
PubMed2006

[Ethical aspects for substitute decisions and their reversion in amyotrophic lateral sclerosis].

Related to its clinical characteristics, amyotrophic lateral sclerosis (ALS) is a paradigm of the ethical difficulties due to a chronic and relentless fatal disease. Its fatal evolution in relation with a respiratory failure, but mainly the choices imposed by the respiratory insufficiency at the end of live, makes that the medical team faces very difficult situations. These situation can be solved only case per case, with repeated discussion with the patients and its relatives. The appeal to the shared dossier becomes essential in this approach. It makes easier the communication, and the appropriation and sharing of information and knowledge that are necessary to anticipate the end of life decisions. ALS sparks off constantly renewed dilemmas.

Amyotrophic Lateral Sclerosis↗
PubMedDate not supplied

Sustaining the edge: factors influencing strategy selection in academic health centers.

Competition within the acute care sector as well as increased penetration by managed care organizations has influenced the structure and role of academic health centers during the past decade. The market factors confronting academic health centers are not dissimilar from conditions that confront other organizations competing in mature industries characterized by declining profitability and intense rivalry for market share. When confronted with intense competition or adverse external events, organizations in other industries have responded to potential threats by forming alliances, developing joint ventures, or merging with another firm to maintain their competitive advantage. Although mergers and acquisitions dominated the strategic landscape in the healthcare industry during the past decade, recent evidence suggests that other types of strategic ventures may offer similar economic and contracting benefits to member organizations. Academic health centers have traditionally been involved in network relationships with multiple partners via their shared technology, collaborative research, and joint educational endeavors. These quasi-organizational relationships appear to have provided a framework for strategic decisions and allowed executives of academic health centers to select strategies that were competitive yet closely aligned with their organizational mission. The analysis of factors that influenced strategy selection by executives of academic health centers suggests a deliberate and methodical approach to achieving market share objectives, expanding managed care contracts, and developing physician networks.

Academic Medical Centers↗