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PubMed1996

The cost of coverage: rural health insurance in China.

China has undergone great economic and social change since 1978 with far reaching implications for the health care system and ultimately for the health status of the population. The Chinese Medical Reform of the 1980s made cost recovery a primary objective. The urban population is mostly protected by generous government health insurance. A high share government budget is allocated to urban health care. Rural cooperative health insurance reached a peak in the mid-1970s when 90% of the rural population were covered. In the 1980s rural cooperative health insurance collapsed and present coverage is less than 8%. The decline has been accompanied by reports of growing equity problems in the financing of and access to health care. This article is the first in a four-year study of the impact on equity of the changes in Chinese health care financing. The article examines the relationship between rural cooperative health insurance as the explanatory variable and health care expenditure, curative vs. preventive expenditure and tertiary curative care expenditure as dependent variables using a natural experimental design with a 'twin' county as a control. The findings support the hypothesis that cooperative health insurance will induce higher growth of health care expenditure. The findings also support the hypothesis that cooperative health insurance will lead to a shift from preventive medicine to curative medicine and to a higher level of tertiary curative care expenditure. The empirical evidence from the Chinese counties is contradicting World Bank health financing policies.

China↗
PubMed2004

Barriers to the treatment of depression in cancer patients.

Major depressive disorder is a relapsing syndrome with grave morbidity and mortality. Much like asthma, it has a genetic predisposition and environmental triggers. Specific antidepressant medications alone, tested in randomized, placebo-controlled studies, show that this is a treatable condition with 65%-70% clinical response. Treatment guidelines written for psychiatric patients and patients in primary care clarify the role of medications and psychotherapy. Physicians are compelled to treat syndromes that are serious and treatable, but barriers to diagnosis and treatment of major depressive disorder in cancer patients include two major barriers to quality medical care generally: uncertainty and cost. Given uncertainty about diagnosis and treatment, cancer physicians with limited time avoid questions about emotions. Cases of depression are often missed. Mental health specialists often work in systems that are separated from oncologists by location, organization, and insurance. Most successful interventions to improve treatment of depressive disorders require multiple strategies: clinical education, enhanced role of nurses, and integrated oncology and specialist care. Recent strategies in oncology settings are reviewed. Research concepts to improve outcomes in treatment of depression include staging of depressive disorder in cancer to reveal prognosis, evaluation of depression outcomes in the context of one tumor type, new organizational models in the acute cancer setting, use of the cancer protocol, and assessment of access to care of depression in cancer survivors. Major depressive disorder in cancer is staged by positive past history, comorbid anxiety disorder or substance abuse, use of specific cancer medications that destabilize mood, and active cancer or no evidence of disease.

Delivery of Health Care↗
PubMed2001

Sedation and analgesia for procedures outside the operating room in children.

There has been a dramatic increase in the number of procedures that are conducted in children in which sedation is now considered beneficial. In many institutions, however, resources and personnel have not been recruited to address this increase in demand. In most institutions, anaesthesiology departments are not able to provide anaesthesia for all procedures that are performed outside the operating theatre, and alternative solutions are needed. Recent research includes attempts to decrease the time required to induce sedation and to recover from it, and development of new organizational models to improve the safety of procedural sedation.

Journal Article↗
PubMed1995

Academic health centers and HMOs: a systems perspective on collaboration in training generalists physicians and advancing mutual interests.

Academic health centers (AHCs) and health maintenance organizations (HMOs) often hold each other at arm's length because of fundamental organizational differences. AHCs view HMOs as too intrusive in the clinical management of patients and too concerned with the financial bottom line. HMOs view AHCs as organizationally fragmented and expensive in providing health care services. AHCs must expand their primary care networks and reassess their mission and public accountability in training a more balanced physician workforce. HMOs are growing rapidly and need well-trained generalist physicians to support that growth. This paper uses an organizational systems model in examining AHCs and HMOs to identify common needs, mutual interests, areas for potential collaboration, and bridging strategies. These include health care systems development, professional education, information management systems, and health services research. As the financing and delivery of health care continue to change and to become more integrated, both organizations have much to gain from collaboration.

Academic Medical Centers↗
PubMed1999

Forum on the future of academic medicine: Session VI--Issues of change and quality in U.S. health care.

The sixth meeting of the AAMC's Forum on the Future of Academic Medicine, on September 10, 1998, opened with a talk by Paul B. Ginsburg, PhD, president of the Center for Studying Health System Change (HSC). He described a major longitudinal study by the HSC of the changing U.S. health care system and reviewed some preliminary findings on topics such as the variety of ways communities are responding to relatively uniform forces driving health care markets; the reasons that uninsured individuals have a much harder time securing needed care in some communities than in others; the changing role of employers as sponsors of workers' insurance; consumers' frequently limited knowledge of their health care plans; the continuing importance consumers attach to having access to a broad choice of providers and the effects of this on the marketplace (e.g., broadening of networks); the different organizational models of care that are evolving; and the changing relationships between primary care physicians and specialists. The second presentation was by Janet M. Corrigan, MD, MBA, who served as executive director of the President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry. She discussed the commission's findings about the state of quality in the health care industry and the commission's strategy to address serious shortcomings (e.g., unevenness of quality; avoidable errors; misuse of services). She also commented on the exponential increase in medical knowledge and the need for systems to help practitioners obtain and use it, and discussed the quality of care inside and outside managed care settings (about the same). Both Dr. Ginsburg and Dr. Corrigan discussed how some of the issues and findings they presented apply to academic medical centers, and responded to penetrating questions and statements of forum members.

Academic Medical Centers↗
PubMed1979

Revisiting "the wobbly three legged stool".

Examination of both the similarities and dissimilarities of the use of the corporate organizational model in the typical hospital has led to the conclusion that the model can, at best, be only a loose fit.

Attitude↗
PubMed1995

Staff nurse work empowerment and perceived autonomy. Testing Kanter's theory of structural power in organizations.

Nurse executives have been striving for the means to equalize the power base in healthcare settings. They also have been seeking ways to overcome the perceived powerlessness of their staffs. Empowerment and increased autonomy in the work setting often are described as mechanisms to achieve these goals. This study, based on Kanter's theory of the structural determinants of behavior in organizations, examined formal and informal power as predictors of job-related empowerment and autonomy. Results of the study lend support to the use of the theory in healthcare settings as a way for nurse executives to develop increased access to the sources of job-related empowerment for their staffs.

Adult↗
PubMed1979

Delivering ambulatory health care: the successful experience of an urban neighborhood health center.

During the past few years, the effectiveness of neighborhood health centers (NHCs) has been questioned, and curtailment of funding has indicated a lack of confidence in this organizational model. This article, however, reports on an urban NHC which has achieved considerable success in delivering health care to its target population at a moderate cost. Fifty-two per cent of all community residents and three-quarters of the children and adolescents were active users of the center. The majority of the patients were from low-income families and had established long-term relationships with center providers. Average visits per patient varied with age, sex, diagnosis and insurance coverage. Center physicians, trained as specialists, functioned primarily as general practitioners delivering preventive services, treating minor injuries and self-limiting diseases, and palliating chronic illness. Preventive care was planned as a focal point of the center's program, but third-party reimbursement policies and the lower priority that many patients placed on nonillness care were two major obstacles to the achievement of this goal. The average cost of health care other than mental health services was approximately $20 per visit and $74 per patient per year. Mental health treatment was more expensive. The findings suggest that reconsideration of the NHC as a viable model for delivering health care to the poor might be worthwhile.

Adolescent↗
PubMed1998

Shifting physician prescribing to a preferred histamine-2-receptor antagonist. Effects of a multifactorial intervention in a mixed-model health maintenance organization.

OBJECTIVES: This study was undertaken to determine whether a program of education, therapeutic reevaluation of eligible patients, and performance feedback could shift prescribing to cimetidine from other histamine-2 receptor antagonists, which commonly are used in the management of ulcers and reflux, and reduce costs without increasing rates of ulcer-related hospital admissions. METHODS: This study used an interrupted monthly time series with comparison series in a large mixed-model health maintenance organization. Physicians employed in health centers (staff model) and physicians in independent medical groups contracting to provide health maintenance organization services (group model) participated. The comparative percentage prescribed of specific histamine-2 receptor antagonists (market share), total histamine-2 receptor antagonist prescribing, cost per histamine-2 receptor antagonist prescription, and the rate of hospitalization for gastrointestinal illness were assessed. RESULTS: In the staff model, therapeutic reevaluation resulted in a sudden increase in market share of the preferred histamine-2 receptor antagonist cimetidine (+53.8%) and a sudden decrease in ranitidine (-44.7%) and famotidine (-4.8%); subsequently, cimetidine market share grew by 1.1% per month. In the group model, therapeutic reevaluation resulted in increased cimetidine market share (+9.7%) and decreased prescribing of other histamine-2 receptor antagonists (ranitidine -11.6%; famotidine -1.2%). Performance feedback did not result in further changes in prescribing in either setting. Use of omeprazole, an expensive alternative, essentially was unchanged by the interventions, as were overall histamine-2 receptor antagonist prescribing and hospital admissions for gastrointestinal illnesses. This intervention, which cost approximately $60,000 to implement, resulted in estimated annual savings in histamine-2 receptor antagonist expenditures of $1.06 million. CONCLUSIONS: Annual savings in histamine-2 receptor antagonist expenditures after this multifaceted intervention were more than implementation costs, with no discernible effects on numbers of hospitalizations. The magnitude of effect and cost savings were much greater in the staff model; organizational factors and economic incentives may have contributed to these differences. More research is needed to determine the generalizability of this approach to other technologies and managed care settings.

Boston↗
PubMedDate not supplied

Qualitative evaluation of a school-based support group for adolescents with an addicted parent.

BACKGROUND: Adolescents with an addicted parent are at risk for physical, emotional, and social problems. They are particularly at risk for developing substance abuse. School-based support groups have been suggested as a beneficial treatment and prevention strategy. OBJECTIVE: To examine the features, critical attributes, processes, and benefits of school-based support groups for adolescents with an addicted parent. METHODS: A qualitative evaluation using the ethnographic method was conducted at two Midwestern suburban high schools. RESULTS: The study resulted in a comprehensive description of school-based support groups and an outline presenting benefits of participation for adolescents with an addicted parent. The benefits of group participation included increased knowledge, enhanced coping, increased resilience, improved relationships, and improved school performance. DISCUSSION: Findings from this study suggest that school-based support groups are beneficial to adolescents with addicted parents. Experiential knowledge is the foundation of these self-help groups. School-based support group participation enhanced self-knowledge and led to self-care and self-healing. The school-based support groups expanded the adolescents' awareness, resulting in their ability to make critical choices that facilitated changes in the dysfunctional pattern. Support group participation empowered youth to make these changes.

Adaptation, Psychological↗
PubMed1995

The organization of the medical practice and implications for delivering quality care.

The attention devoted to quality in health care has focused primarily on hospitals. With the shift in care from hospitals to outpatient clinics and physicians' offices, there has emerged a need to consider how quality should be approached in these settings. This article explores the structural barriers in the typical medical practice that must be removed in order to improve the many dimensions of quality. The typical practice must concentrate on enhancing clinical outcomes, patient satisfaction, and practice productivity. One effective strategy is to form teams of physicians and other staff to work on relevant issues. Another is to focus on how the practice can be defined to better meet the needs of patients.

Efficiency, Organizational↗
PubMedDate not supplied

Citizens' role in health services: satisfaction behavior: Kano's model, Part 1.

When it comes to consumer satisfaction, there is a lack of consensus over the importance of the role of consumers in connection with the quality of services. Widely different points of view exist, ranging from a defense of consumer satisfaction as the ultimate measure of service quality, to its treatment as a commercial issue or as one that merely has to do with image. This first article (part 1 of 2, also in this issue) describes and illustrates Kano's explicative model of how consumer satisfaction behaves and briefly analyzes the main characteristics, advantages, and limitations of the different methods used to assess consumer satisfaction.

Consumer Behavior↗
PubMed1997

Immunization registry: problems and prospects for boosting vaccine coverage of children.

Case studies are presented on three organizational models for immunization registries in local communities: agency-based, facility-based, and population-based systems. The strengths and limitations of the respective approaches are highlighted. Each model faces three similar challenges: generating "real-time" information on the status of children who fall behind on their immunizations, assuring confidentiality of registrants and medical information, and maintaining operations amidst adverse social conditions that are at the root of underimmunization of children. With sufficient resources and cooperation among many private and public interests, registries have considerable potential to increase vaccination coverage among our population.

Child↗
PubMed2005

Applying risk perception theory to public health workforce preparedness training.

Since 9/11, public health has seen a progressive culture change toward a 24/7 emergency response organizational model. This transition entails new expectations for public health workers, including (1) a readiness and willingness to report to duty in emergencies and (2) an ability to effectively communicate risk to an anxious public about terrorism or naturally occurring disasters. To date, however, research on readiness education for health department workers has focused little attention upon the risk perceptions that may influence their willingness to report to duty during disasters, as well as their ability to provide effective emergency risk communication to the public. Here, we apply risk perception factors to explore the potential barriers and remedies to effective public health workforce emergency response.

Attitude of Health Personnel↗
PubMedDate not supplied

Guidelines for effective integration of information technology in the care of HIV-infected populations.

BACKGROUND: Although information technology (IT) plays an increasingly important role in the delivery of healthcare, specific guidelines to assist human immunodeficiency virus (HIV) care settings in adopting IT are lacking. METHODS: Through the experiences of six Special Projects of National Significance - (SPNS) funded HIV-specific IT interventions, key considerations prior to adoption and evaluation of IT are presented. The purpose of this article is to provide guidelines to consider prior to adoption and evaluation of IT in HIV care settings. RESULTS: Six sites conducted comprehensive evaluations of IT interventions between 2002 and 2005, encompassing care delivered to 24,232 clients by 700 providers. Six key considerations prior to adoption of IT in HIV care delivery were identified, including IT and programmatic capacity, expectations, participation, organizational models, end-user types, and challenges. Specific evaluation techniques included implementation assessment, formative evaluation, cost studies, outcomes evaluation, and performance indicators. Grantee experiences are used to illustrate key considerations. DISCUSSION: With proper preparation, even resource-poor HIV care delivery programs can successfully adopt IT.

Guidelines as Topic↗