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PubMed1995

Introducing new mechanical ventilation technology: the hospital perspective.

The introduction of innovative mechanical ventilation technology requires a careful assessment of the cost-benefit relationship of the new technology. Justification for purchase can be sometimes be made on the basis of improved patient safety and physiologic response. Improved patient outcome is much more difficult to demonstrate. It is clear in today's health-care environment that outcome-based research is needed before new technology is introduced to the marketplace, if that new technology is to become part of the average community-hospital complement of mechanical ventilators.

Capital Expenditures↗

PubMed1994

An Internet primer: resources and responsibilities.

The ease with which individuals can access the Internet and with which institutions can make information available on the Internet explains the exponential growth of this national resource. Once one accomplishes the difficult task of installing network services and establishing an ongoing mechanism for their support, it is relatively simple to use software systems such as those described in this article to gainfully traverse the Internet for a wide range of professional activities. But, as we have discussed, every step of the process, from simple naming conventions to organizations and ongoing maintenance of network-based information services, should proceed only after careful consideration of a network growing hourly in complexity. Despite the power of the technology available on one's desktop, one can often be frustrated by the small decisions: what is my colleague's email address? How can I most effectively find relevant information on home health care software? How should I organize a gopher server? When is WAIS preferable to Gopher or W3? Who will help me learn more? The process comes full circle back to academic medical institutions. The usefulness of the Internet hinges upon the policies these institutions create to aid the organization and dissemination of medical information, and in the means they use to make their constituents aware of the pitfalls and potentials of various technologies.(ABSTRACT TRUNCATED AT 250 WORDS)

Computer Communication Networks↗

PubMed2000

The interdependence of mental health service systems: the effects of VA mental health funding on veterans' use of state mental health inpatient facilities.

BACKGROUND: There are relatively few published data on how the financial structures of different health systems affect each other. With increasing financial restrictions in both public and private healthcare systems, it is important to understand how changes in one system (e.g. VA mental healthcare) affect utilization of other systems (e.g. state hospitals). AIMS OF THE STUDY: This study utilizes data from state hospitals in eight states to examine the relationship of VA per capita mental health funding and state per capita mental health expenditures to veterans' use of state hospitals, adjusting for other determinants of utilization. METHODS: This study utilized a large database that included records from all male inpatient admissions to state hospitals between 1984 and 1989 in eight states (n = 152541). Funding levels for state hospitals and VA mental health systems were examined as alternative enabling factors for veterans' use of state hospital care. Logistic regression models were adjusted for other determinants of utilization such as socio-economic status, diagnosis, travel distances to VA and non-VA facilities and the proportion of veterans in the population. RESULTS: The single strongest predictor of whether a state hospital patient would be a veteran was the level of VA mental healthcare funding (OR = 0.81 per $10 of funding per veteran in the population, p = 0.0001), with higher VA funding associated with less use of state hospitals by veterans. Higher per capita state funding, reciprocally, increased veterans' use of state hospitals. We also calculated elasticities for state hospital use with respect to VA mental healthcare funding and with respect to state hospital per capita funding. A 50% increase in VA per capita mental health spending was associated with a 30% decrease in veterans' use of state hospitals (elasticity of -0.6). Conversely, a 50% increase in state hospital per capita funding was associated with only an 11% increase in veterans' use of state hospitals (elasticity of 0.06). IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: These data indicate that per capita funding for state hospitals and VA mental health systems exerts a significant influence on service use, apparently mediated by the effect on supply of mental health services. Veterans are likely to substitute state hospital care for VA care when funding restrictions limit the availability of VA mental health services. However, due to the relative sizes of the two systems, VA funding has a larger effect than state hospital funding upon state hospital use by veterans. IMPLICATIONS FOR HEALTH POLICIES: These data indicate that changes in the organizational and/or financial structure of any given healthcare system have the potential to affect surrounding systems, possibly quite substantially. Policy makers should take this into account when making decisions, instead of approaching systems as independent, as has been traditional. IMPLICATIONS FOR FURTHER RESEARCH: Further research is needed in two areas. First, these results should be replicated in other systems of care using more recent data. Second, these results are difficult to generalize to individual behavior. Future research should examine the extent and individual determinants of cross-system use.

Journal Article↗

PubMed2000

Dignity or denial? Decisions regarding initiation of dialysis and medical therapy in the institutionalized severely mentally retarded.

Decisions regarding health care of the severely mentally retarded can be difficult. We present 2 cases of patients with severe mental retardation who lived in long-term care facilities. Both patients had progressive loss of renal function and eventually reached end-stage renal disease. In each case, the decision was made not to initiate dialysis. We discuss issues of dialysis and medical care of the severely mentally retarded and advocate using the principles of "best respect" and "best interest" in making medical decisions in this population.

Adult↗

PubMed2003

Do you know who will be vaccinated at your ED?

The administration of the smallpox vaccine is imminent, so emergency department managers are making difficult decisions about which individuals should be vaccinated. If all attending physicians are vaccinated, these individuals can care for patients with suspected smallpox. Consider offering vaccine first to staff who have been immunized previously. Survey staff to find out which individuals have contraindications for the vaccine.

Decision Making, Organizational↗

PubMed1996

Economic issues in the development and use of practice guidelines: an application to resource allocation in dentistry.

In this paper, the extent to which practice guidelines using cost-effectiveness data can be used to inform programme decisions is analysed. In particular it is shown that guidelines aimed at informing individual patient-provider decisions are unable to reflect the economic concepts that are required to inform public decisions concerned with making best (i.e., most productive) use of the resources available to serve defined populations. The research on which practice guidelines are based represents an important but incomplete source of information for taking decisions about which clients to serve, with which services, and when in the disease process, in the context of provision of services to groups or populations. Moreover, the inappropriate use of 'individually focused' guidelines to inform 'collectively-focused' decisions can lead to more harm than good. An alternative approach for dealing with the difficult choices faced by decision makers involved in public programmes is identified. An illustration of the proposed approach is presented concerning the provision of pit and fissure sealants to children served by a public health clinic.

Child↗

PubMed1993

Questions of life and death.

The continuous evolution of health care technology has brought with it a growing need to evaluate the quality of the lives it saves or prolongs. Do Not Resuscitate (DNR) orders, euthanasia and living wills all raise the issue of who decides about the quality of a person's life. Although nurses and other health care professionals have developed codes of ethics to deal with these difficult evaluations, ethics are not law. Ethics are derived from culture, religion and societal and individual concepts of morality. Law is the set of rules a society chooses to enact and enforce. Real difficulty arises when health care providers must face a situation where personal and professional codes of ethics clash with the law.

Decision Making↗

PubMedDate not supplied

Clinical decision making in patients with congestive heart failure: the role of thoracic electrical bioimpedance.

Optimizing appropriate pharmacologic therapy in patients with congestive heart failure has been difficult due to a lack of easily obtainable hemodynamic information to guide the approach to the patient. Recently, thoracic electrical bioimpedance has allowed reliable outpatient determination of these hemodynamic variables, potentially allowing tailored adjustment of therapy in patients with cardiac dysfunction. Case studies are presented in which bioimpedance data were important contributing factors in optimizing patient management. Utilization of this new technology to individualize patient therapy should lead to improved outcomes and more efficient use of health care resources. (c)2000 by CHF, Inc.

Journal Article↗

PubMed2003

A 'real puzzle': the views of patients with epilepsy about the organisation of care.

BACKGROUND: Little is known about how individuals who have a diagnosis of epilepsy have experienced healthcare services or their views about how they should best be organised to meet their ongoing needs. METHODS: Focus group interviews. Individuals with epilepsy were identified in 5 practices in Wales: 90 were invited, 40 confirmed attendance and 19 individuals attended interviews in 5 groups of size 6, 5, 4, 3 and 1 (Table 2). INCLUSION CRITERIA: individuals with a confirmed diagnosis of epilepsy, aged between 18-65. The exclusion criteria were learning disability or an inability to travel to interview locations. RESULTS: The individuals in these group interviews were not 'epilepsy activists' yet they remained critical in extended discussions about the services encountered during their patient careers, wanting more information and advice about how to adapt to problems, particularly after initial diagnosis, more involvement in decision making, rapid access to expertise, preferably local, and improved communication between clinicians. A central concern was the tendency for concerns to be silenced, either overtly, or covertly by perceived haste, so that they felt marginalised, despite their own claims to own expert personal knowledge. CONCLUSIONS: Users of existing services for epilepsy are critical of current systems, especially the lack of attention given to providing information, psychosocial support and the wishes of patients to participate in decision making. Any reorganisation of services for individuals with epilepsy should take into account these perceived problems as well as try to reconcile the tension between the distant and difficult to access expertise of specialists and the local but unconfident support of generalists. The potential benefit of harnessing information technology to allow better liaison should be investigated.

Delivery of Health Care↗

PubMed1997

Implementing programs for chronic illness management: the case of hypertension services.

BACKGROUND: This article describes the process by which HealthSystem Minnesota (a vertically integrated health care organization), functioning in a competitive managed care environment, has been implementing a hypertension services program. The program involves a team approach to care, with emphasis on patient participation in treatment; decentralized care delivery by nurse coordinators at primary care practice sites; ongoing training and education for patients and providers; and the continuous monitoring and evaluation of patient outcomes and satisfaction. JOB-LEVEL ISSUES: A variety of issues, such as the role and responsibilities of the nurse coordinator, became evident as the program moved towards operational status at four primary care practice sites, which prolonged the implementation period. PROCESS-LEVEL ISSUES: Issues relating to work process changes were more complicated to resolve and required, in some cases, changes in the proposed model. The most significant process-level issues related to educating physicians about the program to secure their participation and support. ORGANIZATION-LEVEL ISSUES: Such issues, which were the most difficult for program implementors to anticipate and resolve, included an organizational culture that emphasized decision making autonomy at primary practice sites. In part, the difficulty encountered in resolving organization-level issues reflected the implementors' lack of awareness of the strength or complexity of the environmental pressures facing the organization, as well as a lack of sensitivity to nuances relating to organizational culture. MOVING AHEAD: Two groups of hypertensive patients--at the implementation and comparison sites--will be compared with respect to satisfaction with care, clinical outcomes, and costs. Expansion of the model to patients with other chronic conditions is under consideration.

Case Management↗

PubMed1992

[Management of beta-thalassemias in a developing country. Experience of a pediatric service in Oran (Algeria)].

The management of beta-thalassemia in a developing country faces a host of organizational, logistic, and funding problems. Experience acquired against this background of multiple deficiencies is reported here. Only 60% of children with documented beta-thalassemia were monitored more or less regularly. The remaining 40% died or were lost to follow-up. Clinical results were acceptable in terms of growth but transfusion goals (pretransfusion Hb greater than or equal to 10 g/dl) were achieved in only 7% of cases and adverse effects to transfusions proved difficult to prevent. Lastly, funding remained grossly inadequate since only 5.4% of actual costs in drugs and small equipment were covered. This lack of funds has a major impact on decision-making concerning the care of this type of patient.

Adolescent↗

PubMed1995

The independent practice association in theory and practice. Lessons from experience.

This article examines an advanced managed care area, the San Francisco East Bay Area in California, for basic organizational issues posed by managed care for the medical profession. Of the three basic structures found, the independent practice association (IPA) model is theoretically most promising. Unlike the integrated health plan, the IPA seeks to retain traditional practice autonomy. Unlike the isolating direct gatekeeper model, the IPA assembles physicians in self-directed groups to invent and implement solutions and to exert political influence upward. In practice, however, it has proved difficult to balance practice autonomy with IPA authority. Both large, successful East Bay Area IPAs show signs (perhaps inevitably) of favoring authority over autonomy, as shown by their policies on governance, membership, and administration. Several policies are suggested to help redress this balance. Medical leaders must act now, before all the evidence is in, or the institutions of the past--hospitals and insurance companies--will control our future.

Decision Making, Organizational↗

PubMed2000

Nursing home placement: an exploration of the experiences of family carers.

This study examines some of the factors leading family carers to place their older relatives in a nursing home. It also explores their thoughts and feelings about their relatives' admission to a nursing home. Analysis of in-depth interviews with relatives (n=10) found that the decision to place an older relative in a nursing home was a difficult one for families. The interviewed carers stated that admission to a nursing home was held off as long as possible but the deteriorating health of the older relative and in some cases their own health meant that there was no other option. Admission to institutional care usually followed a period of prolonged home care and occurred at a time of crisis. Family carers complained that they were given inadequate support from health care professionals and often had no choice in the decision-making process. This was particularly evident in the case of carers whose relative was transferred directly from hospital to a nursing home setting. The majority of carers in this study experienced ambiguous feelings about placing their elderly relative in a nursing home. Feelings of relief that the burden of care had been lifted, contrasted sharply with feelings of guilt that they could not continue with their 'duty of care'. Families also felt a need to justify their decision by emphasizing how friends and other family members agreed that they could not continue with home care in the interests of both their own and the older relative's health. The findings suggest that while many carers are relieved of the physical exhaustion surrounding home care, the emotional turmoil continues long after admission to a nursing home.

Activities of Daily Living↗

PubMed1996

Prospective, controlled study of the outcome of human immunodeficiency virus-1 antibody-positive children admitted to an intensive care unit.

OBJECTIVE: Intensive care resources are both scarce and costly in South Africa. We set out to ascertain whether human immunodeficiency virus (HIV) status affects the spectrum of disease and the prognosis in children treated in pediatric intensive care units (ICUs). DESIGN: A prospective, case-controlled study. SETTING: The pediatric ICU at Kind Edward VIII Hospital, Durban, South Africa. PATIENTS: HIV-positive cases were classified as "acquired immunodeficiency syndrome," "symptomatic HIV," and "HIV-unrelated diseases." Controls were matched for age, race, gender, severity of disease, and admitting diagnosis. MEASUREMENTS AND MAIN RESULTS: THe clinician was blinded to the serostatus of patients. Informed consent and Ethics Committee approval were obtained for HIV testing and the study. Outcome measures were the duration of intermittent positive-pressure ventilation and ICU stay, maximum ventilatory requirements, infectious complications, and mortality. There were 11 cases of acquired immune deficiency (AIDS), 24 cases of symptomatic HIV, and 13 cases of HIV-unrelated diseases. Mortality rates for the three groups were as follows: 100% in patients with AIDS compared with 55% in their controls (p<.01); 38% in patients with symptomatic HIV and 46% in controls. Cytomegalovirus and Pneumocystis carinii infections were significantly increased (p<.01, p<.002, respectively) in patients with AIDS as compared with controls. Outcome measures were similar in those patients with symptomatic HIV and those patients with HIV-unrelated diseases, as compared with their respective controls. CONCLUSIONS: Outcome in children with AIDS admitted to the pediatric ICU was significantly worse than the outcome in HIV-uninfected children. However, the number of AIDS patients studied was small. HIV antibody-positive children without AIDS do as well as uninfected controls. Ethics committees in resource-constrained countries may be assisted by such data when making difficult decisions on the admissions of HIV-infected patients to pediatric ICU facilities.

Acquired Immunodeficiency Syndrome↗

PubMed2005

The woman patient after WHI.

An epidemic of fear and distrust has infected women (and physicians) after publication of the Women's Health Initiative (WHI). The overinflated negative data emerging from the oestroprogestinic arm of WHI have frightened women and gave rise to the most difficult emotions to cope with. Keywords such as cancer, death and hormones combined together, have potentiated an avoidant attitude towards hormonal therapy (HT) driven more emotionally than rationally. This negative aura has not been dissipated by the positive data from the oestrogen-only arm of WHI. This paper will discuss: women's different emotional reactions to and coping strategies for HT-related fear after WHI; the communication skills physicians should use in focusing on positive messages emerging from WHI; predictors of current HT use; the meaning of the higher use of HT in postmenopausal highly-educated women and women gynaecologists; the importance of increasing healthy life-styles as a taking of responsibility towards aging by every woman; shifting from passivity to active sharing of the decision making process with the caring physician; and the use of an individually tailored HT, when appropriate, as part of an active strategy in the pursuit of a longer health expectancy.

Anxiety↗

PubMed2000

A study of factors associated with cost and variation in prescribing among GPs.

BACKGROUND: Inappropriate prescribing has the potential to harm both the individual and society. Previous research has identified doctor or demographic characteristics that influence prescribing variation but which were not amenable to change. OBJECTIVES: To identify modifiable factors associated with GP prescribing variance and cost. METHOD: Qualitative research methods were used in semi-structured taped interviews with 17 GPs in Avon, South West NHS Region, UK. RESULTS: GPs considered themselves cautious and conservative prescribers. Prescribing decisions often were justified by the prescriber, despite conflicting clinical or cost arguments. A personally developed drug formulary was used to reduce dilemmas potentially associated with prescribing uncertainty. Willingness to reflect upon, and measure, prescribing habits against set professional standards varied considerably. The absence of monitoring mechanisms of prescribing decisions, coupled with under utilization of the community pharmacist, resulted in uncertain prescribing outcomes. Some GPs found it difficult to keep up to date professionally due to perceived time constraints. Excessive patient demand was considered to influence their prescribing, but GPs stated that they were not unduly influenced by the drug representative. CONCLUSIONS: Prescribing makes a considerable impact on health and budgets and yet remains a contentious issue. Improved partnerships between patient, doctor and pharmacist must be established. Better prescribing decision monitoring and support through policy development and educational intervention is needed to reduce prescribing uncertainty. Newly established Primary Care Groups may need to reflect upon the difficulties facing prescribers, particularly when prescribing within cash-limited budgets, to avoid discord between prescribing behaviour and local policy development.

Adult↗

PubMed1995

Synthesis: what can we learn from international experience?

International experience shows that rationing can occur through exclusions or through the use of guidelines. Oregon has chosen to ration by excluding certain services in order to move towards universal population coverage. New Zealand has avoided exclusions and has chosen to ration through the use of guidelines. The Netherlands is pursuing both approaches. The experience of these and other countries demonstrates that rationing is inherently difficult. Choices in health care can be informed by techniques drawn from economics and other disciplines but these techniques need to be used as part of debate and discussion in the process of arriving at decisions. Experts and the public can contribute to this process and strenuous efforts need to be made to ensure participation by a representative cross-section of the population. At its root priority setting is a political process shaped by beliefs and values. Increased transparency in decision making should promote greater accountability and increased public awareness of the nature of rationing.

Health Care Rationing↗

PubMedDate not supplied

The ethical imperative in health services governance and management.

Increasingly, administrative and biomedical ethical issues affect decision making in health services organizations. Although the ethics of biomedical decision making affect governance and management, this article is limited to administrative ethics: fiduciary duty, conflicts of interest, confidential information, resource allocation, and consent. Those who govern and manage health services organizations face an ethical imperative: They are moral agents with an independent duty to protect patients and further their interests. This duty is separate from any existing between care givers--such as physicians--and patients. It may complement other relationships, but it is always present. This imperative will become more difficult to attain. The potential conflict between economic and patient interests lies close to the surface in the patient care relationship, and maintaining it undoubtedly will be exacerbated by competitive pressures. The ethical implications of this conflict for those who govern and manage health services organizations are enormous.

Confidentiality↗