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PubMedDate not supplied

Patients first: small hospitals in Ontario favour patient-focused care.

Is patient-focused care the model of the future? In 1993, CEOs of selected small hospitals across Ontario were asked if the patient-focused-care model is used in their facilities and, if so, to provide examples of some of the activities involved. This article presents a summary of the study's findings, discusses the model's merits and challenges for implementation, and offers several recommendations to assist hospitals contemplating the introduction of this model of health care delivery.

Evaluation Studies as Topic↗
PubMed1994

Applying stakeholder analysis to health care administration education.

Demographic trends and budgetary constraints at many universities suggest that education will not be "business as usual" in the next several years. Academic programs in health care administration can enhance their ability to respond to these challenges by implementing stakeholder analysis as part of their strategic planning process. This article delineates the stakeholder groups which typically influence programs in health care administration and presents a systematic manner of analyzing their relationships to the program in terms of values and beliefs, power, cooperative potential, and likely issues. Actions to strengthen relationships with each stakeholder group are noted. Finally, the utility and limitations of stakeholder analysis are discussed.

Decision Making, Organizational↗
PubMed1997

Measuring outcomes in the changing environment of child welfare services.

Child welfare service organizations are undergoing profound changes with the advent of managed care. Expensive development of new infrastructures is required, including information systems to track services and outcomes. The authors examine key considerations in designing an outcomes measurement program for child welfare agencies and challenges for implementation. In addition, they review national initiatives to determine best practices for outcomes measurement of children's services, and how these initiatives can help guide others' efforts.

Child Health Services↗
PubMed1996

Diagnostic risk adjustment for Medicaid: the disability payment system.

This article describes a system of diagnostic categories that Medicaid programs can use for adjusting capitation payments to health plans that enroll people with disability. Medicaid claims from Colorado, Michigan, Missouri, New York, and Ohio are analyzed to demonstrate that the greater predictability of costs among people with disabilities makes risk adjustment more feasible than for a general population and more critical to creating health systems for people with disability. The application of our diagnostic categories to State claims data is described, including estimated effects on subsequent-year costs of various diagnoses. The challenges of implementing adjustment by diagnosis are explored.

Adolescent↗
PubMed1999

Tailoring a corporate compliance program for an IDS.

Integrated delivery systems (IDSs) face a particular challenge in implementing a corporate compliance program--that of ensuring the program addresses issues of compliance with payment rules and regulations consistently across every component of the health system. To successfully implement an effective compliance program, the various components of the IDS first must understand what such a program is intended to accomplish, and any internal resistance to developing the program must be overcome. The IDS then can undertake identifying and assessing areas of the health system at risk of being in noncompliance, designing and implementing the program, auditing claims processing and cost reporting throughout the health system to ensure systemwide compliance, and maintaining the program through ongoing monitoring and training.

Costs and Cost Analysis↗
PubMedDate not supplied

Cost-effectiveness and coverage policy.

Cost-effectiveness analyses have become a pervasive element of health care. But they have not had a major impact on medical coverage policy. The challenge of implementing cost-effectiveness as a medical coverage criterion is related to the following issues: (1) Contract language does not include cost-effectiveness as a coverage criterion; (2) cost-effectiveness analyses often take the societal, population-based perspective, while health care is delivered on an individual basis; (3) there is no standard methodology for cost-effective analysis; (4) there is no explicit cut-off between cost-effective and cost-ineffective; and (5) cost-effectiveness analyses are not time sensitive.

Community Health Planning↗
PubMed1999

Using contact capitation to align payment incentives among specialists.

Contact capitation is a means of paying specialists based on the number of patients managed rather than on the number of services provided or procedures performed. Payments to physicians are disbursed from budgets, or risk pools, which are established by specialty and product line (e.g., commercial coverage, Medicare). Each specialist is credited with managing a patient for a specified time period (usually 12 months) following the patient's initial visit. To ensure payments are equitable to all physicians, regardless of specialty or subspecialty, the system may be adjusted by using different contact weights for certain diagnoses or procedures, creating subpools for selected subspecialties and/or procedures, establishing separate capitation rates for different age segments, and setting aside certain specialties as fee-for-service carve-outs. Contact capitation has advantages over traditional specialist capitation of removing physicians' financial incentives to overutilize and allowing for a broad physician specialty panel. Challenges to implementing contact capitation include getting physicians to alter habitual practice patterns and managing the system's administrative complexity.

Capitation Fee↗
PubMed2001

Challenges of managed care organizations in treating respiratory tract infections in an age of antibiotic resistance.

Managing respiratory tract infections (RTIs) presents many challenges to managed care organizations (MCOs). RTIs are among the most common illnesses treated by primary care clinicians; they seriously impact patient quality of life and are a leading cause of health-related absences from the workplace. The total direct costs of treating conditions such as acute otitis media, sinusitis, and acute exacerbations of chronic bronchitis are estimated to be $10.1 billion. The development of drug resistance has compounded these challenges by increasing treatment failures and costs and limiting treatment options. MCOs can meet these challenges by implementing clinical practice guidelines for acute respiratory infections, conducting focused studies of antibiotic use, and educating both healthcare clinicians and patients about appropriate antibiotic use.

Acute Disease↗
PubMed2002

Disease management practices of health plans.

OBJECTIVE: To investigate how health plans manage chronic diseases. STUDY DESIGN: Health plan medical directors were surveyed regarding the disease management (DM) practices of their plans. METHODS: We took a stratified random sample of 65 plans, all members of the American Association of Health Plans. Forty-five plans responded. Results were weighted to be representative of the industry (including nonmember plans). Medical directors were asked to consider that they had a DM program only if 2 things were true: (1) A majority of a plan's enrollees could not be ineligible for a DM program for non-clinical reasons (eg, geographic location); and (2) a DM program had to have at least 6 of the 8 components of a DM program as defined by the Disease Management Association of America. RESULTS: The 3 diseases most likely to be the focus of DM programs were diabetes, asthma, and congestive heart failure. For each of these diseases, at least one quarter of Americans were enrolled in plans offering a DM program. Medical directors perceived their DM programs to be highly effective in reducing mortality and morbidity and in improving the functional status of patients, and perceived them to be effective in lowering cost. The greatest challenge in implementing DM programs involves information technology. These results yield insights into the future of treatment of chronic disease in the United States. CONCLUSION: Health plans have made a significant investment in programs to improve care for chronic illness. The almost universality of DM programs highlight the need for scholarly evaluations of their effectiveness and cost effectiveness.

Asthma↗
PubMed2002

Controlling multidrug-resistant tuberculosis and access to expensive drugs: a rational framework.

The emergence and spread of multidrug-resistant tuberculosis (MDR-TB), i.e. involving resistance to at least isoniazid and rifampicin, could threaten the control of TB globally. Controversy has emerged about the best way of confronting MDR-TB in settings with very limited resources. In 1999, the World Health Organization (WHO) created a working group on DOTS-Plus, an initiative exploring the programmatic feasibility and cost-effectiveness of treating MDR-TB in low-income and middle-income countries, in order to consider the management of MDR-TB under programme conditions. The challenges of implementation have proved more daunting than those of access to second-line drugs, the prices of which are dropping. Using data from the WHO/International Union Against Tuberculosis and Lung Disease surveillance project, we have grouped countries according to the proportion of TB patients completing treatment successfully and the level of MDR-TB among previously untreated patients. The resulting matrix provides a reasonable framework for deciding whether to use second-line drugs in a national programme. Countries in which the treatment success rate, i.e. the proportion of new patients who complete the scheduled treatment, irrespective of whether bacteriological cure is documented, is below 70% should give the highest priority to introducing or improving DOTS, the five-point TB control strategy recommended by WHO and the International Union Against Tuberculosis and Lung Disease. A poorly functioning programme can create MDR-TB much faster than it can be treated, even if unlimited resources are available. There is no single prescription for controlling MDR-TB but the various tools available should be applied wisely. Firstly, good DOTS and infection control; then appropriate use of second-line drug treatment. The interval between the two depends on the local context and resources. As funds are allocated to treat MDR-TB, human and financial resources should be increased to expand DOTS worldwide.

Antitubercular Agents↗
PubMed2002

The primary therapist model: addressing challenges to practice in special education.

When occupational therapy (OT) and physical therapy (PT) are provided as related services in educational settings, federal law, professional guidelines, and validated practices have pointed to appropriate models of service provision. Issues such as personnel shortages, professional isolation, and questionable educational relevance of services all create barriers to use of recommended practices. The overlap between OT and PT in special education suggests one strategy to help address these barriers: a primary therapist model. In this model, an OT or PT is assigned as primary therapist, with consultation from the other discipline as required to meet student needs. Potential benefits of the model, challenges in implementation, the best practice framework needed to support the model, and the need for research on costs and benefits are discussed.

Adolescent↗
PubMed2002

Surveillance for traumatic brain injury deaths--United States, 1989-1998.

PROBLEM/CONDITION: Data indicate that approximately 50,000 U.S. residents die as a result of traumatic brain injury (TBI) annually. Survivors of TBI are often left with neuropsychologic impairments that result in disabilities affecting work or social activity. During 1979-1992, TBI-related death rates declined 22%, from 24.6 to 19.3 deaths/100,000 population. This report describes the epidemiology and trends in TBI-related mortality during 1989-1998. REPORTING PERIOD: January 1, 1989-December 31, 1998. DESCRIPTION OF SYSTEMS: The National Center for Health Statistics (NCHS) Multiple Cause of Death public use data were analyzed for this study. RESULTS: During 1989-1998, an annual average of 53,288 deaths (range: 51,848-54,501) among U.S. residents were associated with TBI. TBI-related death rates declined 11.4%, from 21.9 to 19.4/100,000 population. The major causes of TBI-related deaths were firearm-related (40%), motor-vehicle-related (34%), and fall-related (10%). The leading causes of TBI-related deaths differed among age groups. Among youths aged 0-19 years, motor-vehicle-related TBIs were the leading cause; among persons aged 20-74 years, firearm-related TBIs were the leading cause; and among persons aged > or = 75 years, fall-related TBIs were the leading cause. Comparing rates in 1989 with rates in 1998, motor-vehicle-related causes declined by 22%; the majority of this decline occurred during the first 5 years of the period. During 1989-1998, firearm-related TBI-related deaths declined by 14%; approximately all of this decline occurred during the last 5 years of the period. In contrast, fall-related TBI-related death rates increased by 25% during the period. CONCLUSION: This analysis of mortality data identifies recent trends in TBI-related deaths occurring during 1989-1998. Fall-related TBI death rates have increased throughout the period. Firearm-related TBI death rates, which were increasing in the early 1990s, declined. Motor-vehicle-related TBI death rates, which were decreasing until the mid-1990s, have since demonstrated only a limited change. PUBLIC HEALTH ACTION: More current population-based epidemiologic studies of TBI are needed to assess recent trends of etiologic factors, provide additional guidance for public policy, and evaluate prevention strategies. Despite the decline in fatal TBI incidence, TBI morbidity and mortality remains a public health challenge. Public health, law enforcement, and transportation safety professionals can address these challenges by implementing effective interventions based on a thorough assessment of the factors that influence health-related behaviors.

Accidental Falls↗
PubMed2000

Oregon's guidelines for physician-assisted suicide: a legal and ethical analysis.

Oregon's Death with Dignity Act was first passed by a ballot initiative in 1994, but numerous judicial challenges delayed implementation of the Act. In November of 1997, following the United States Supreme Court decisions in Vacco v. Quill and Washington v. Glucksberg, which left the states' power to regulate physician-assisted suicide undisturbed, the Oregon voters upheld their law. Oregon remains the only state in the nation to authorize physician-assisted suicide. The Task Force to Improve the Care of Terminally Ill Oregonians published a Guidebook for health care providers on the Oregon Act, and the New England Journal of Medicine recently issued a special report on the first year's experience under the Act. This paper analyzes the legal context of the Oregon Death with Dignity Act, discusses the efficacy of the tenets in the Guidebook, and explores ethical issues underlying the guidelines, particularly those pertaining to the meaning of a patient's request for assisted suicide and processes supporting informed consent.

Adult↗
PubMed1998

The integrated operating room system - a pathway to the or 2000 and beyond.

The need to create a new kind of operating room (OR) is obvious from the situation today. Although a number of innovative and even futuristic OR concepts have been proposed, the challenge to implement the OR of the future has never been met. In the Integrated OR System project we came to the conclusion that we have to proceed to new values and new approaches to make the OR of the next millennium happen. By following those new roads we will not only overcome the deficiencies of the OR today but also create a platform that allows easy inclusion of upcoming technology.

Journal Article↗
PubMed2002

Incentives in financing mental health care in Austria.

BACKGROUND: In Austria, financing health care -and even more so mental health care- is characterized by a mix of federal and provincial responsibilities, lack of uniformity in service provision and service providers, and diverse funding arrangements. The division between financing structures for health care and social care makes the situation even more complex. This state of affairs results in various, partly counterproductive and sometimes paradoxical financial incentives and disincentives for the providers, recipients and financiers of mental health services. In several provinces of Austria, recent reform plans in mental health care have focused strongly on establishing community-based and patient-oriented mental health care. One of the main challenges in implementing this new policy is the re-allocation of resources. AIMS OF THE STUDY: The authors hypothesize that the existing structure of mental health care financing, with its incentives and disincentives, constitutes an obstacle to patient-oriented community-based mental health care. Analyzing the characteristics of the overall mental health care financing system in one Austrian province, Lower Austria, will provide a better understanding of actor-relationships and inherent incentives and highlight implications for the process of deinstitutionalization. METHOD: The authors used an analytical framework based on the principal-agent theory, empirical evidence, and information on financial, organizational and legal structures to identify the characteristics of actor-relationships and the position of single actors within the system. RESULTS: The article shows how incentives are linked to existing constellations of actors involved in mental health care financing and identifies significant power relations. As a consequence, incentives and disincentives within the financing system result in hospital- centered and supply-oriented mental health care in Lower Austria. DISCUSSION: The current system of financing mental health care provides an obstacle to the provision of patient-oriented and community-based mental care. This is due to existing constellations and power relations among the actors where, most importantly, patients are the weakest party in the patient-payer-provider triangle. Balancing power relations will be a significant prerequisite for alternative financing systems. IMPLICATIONS FOR HEALTH POLICIES AND FURTHER RESEARCH: If a community and needs-based mental health care system is to be established in Austria, the financing structures have to be changed accordingly. Applying a principal-agent framework is useful for identifying key aspects in mental health care financing in relation to the provision of services. Further research is needed to help develop alternative financing mechanisms that support community-based and patient-oriented mental health care systems.

Austria↗
PubMed2003

[Malaria situation in the People's Republic of China in 2002].

This summary was made on the basis of the annual reports of malaria control from the professional institutions in the 21 Provinces/Municipality/Autonomous Region (P/M/A). The number of malaria cases reported in the country was 35,298 in the year 2002 and the incidence rate was 0.348/10,000, an increase of 68.2% than that of the last year and the largest increase since 1994. The total number of suspected cases was 136,902, and the death toll due to malaria was 42. Based on the numbers of malaria cases and suspected cases from the case reporting system of P/M/A, and on the field investigations of the cases missed (failed to report), the estimated total number of malaria cases was 387,000 in 2002. In the South, the provinces of Yunnan and Hainan have been the major area of malaria historically. About 50% of the reported cases in the country were from the two provinces in 2002. There were 12,218 cases reported from Yunnan with 33 deaths, the incidence was 3.026/10,000, 31.6% increase than that in the last year. Among the reported cases, 2,922 were cases of falciparum malaria. The estimated number of malaria cases was 18 times more than that reported. The number of reported cases in Hainan was 5,354 with an incidence of 6.645/10,000, 15.5% increase than that of the last year; there were 1,210 cases of falciparum malaria, and 1 death. The estimated number of malaria cases was 100,000. Covered were also the other P/M/A in the South: Fujian, Guizhou, Guangxi, Guangdong, Sichuan and Chongqing. In Fujian province, 92 malaria cases were reported, all imported, with an incidence of 0.028/10,000 which increased by 272.8% than that in the last year. There were 713 cases reported in Guizhou with an incidence of 0.193/10,000, increased by 17.1%. The number of reported malaria cases was 392 in Guangxi, with an incidence rate of 0.082/10,000, increased by 14.0%. The incidence slightly decreased in Sichuan, Guangdong and Chongqing, and the case number was 443, 403 and 130 respectively. The cases from the 6 provinces/municipality occupied 6.2% of all cases reported from the country. The 5 provinces in central China were also important in malaria control program. Hubei province reported 5,101 malaria cases (incidence 0.895/10,000), increased by 161.6% than that of the last year; plus suspected cases of 5,614, the total number of malaria cases was estimated to be 11,000. The number of reported cases in Anhui province was 5,999 (0.958/10,000), second largest to that of Yunnan province, increased by 123.6%; with 22,615 suspected cases, the total number of malaria cases was estimated to be 28,000. The case number reported in Henan and Jiangsu provinces was 2,921 and 686 respectively, the incidence decreased by 35.1% and 41.7% respectively, but in Shandong province, 52 cases reported with an increase of 23.8%. Focal outbreaks occurred in 81 villages of 17 counties in the provinces of Hubei, Anhui, Henan and Jiangsu, where Anopheles sinensis is the principal transmitting vector. Malaria cases reported from the 5 provinces in central China accounted for 42% of the national figure. Three hundred and thirteen and 229 cases respectively reported from Hunan and Zhejiang provinces, the incidence increased by 44.2% and 288.1% with 3 and 1 death respectively. There were 28 cases in Jiangxi province with a little fluctuation situation. In Shanghai, 135 cases were recorded with an increase of incidence by 66.7%; 16 were infected locally and others all imported. In the provinces of Shaanxi, Shanxi, Liaoning and Gansu, sporadical malaria cases were still reported. The number of Plasmodium falciparum malaria cases was 4,319, accounting for 12.2% of the total cases; of which 13.4% (556) were imported cases. The locally infected falciparum malaria was found in 61 counties/cities of Hainan, Yunnan, Guangxi, and Shaanxi; of which 42 counties/cities were in Yunnan, increased by 11, 16 counties/cities in Hainan, increased by 5, 2 counties in Guangxi and 1 county in Shaanxi. Imported falciparum malaria cases were reported in 114 counties of 14 P/M/A, 2 provinces less but 6 counties more than that in 2001. Due to the strengthening of surveillance and effective management of dubious epidemic conditions, there was no local transmission of falciparum malaria in the above provinces except 2 locally infected cases in Guangxi and 1 in Shaanxi. In areas where the transmission of falciparum malaria has been interrupted but vectors and transmission conditions exist, it is of great importance to prevent the transmission of falciparum malaria by imported source of infection. The main reasons for the considerable increase of malaria transmission in 2002 were as follows: the provinces of Yunnan and Hainan still faced a severe situation of malaria epidemic with a spread of Plasmodium falciparum, especially in the mountainous area of Hainan and the 25 frontier counties in the south and west of Yunnan. Following the development of economy and trade, more frequent population movement occurred among the provinces and between Yunnan and bordering countries, malaria situation becomes more challenging. In central part of the country including Hubei, Anhui, Henan and Jiangsu, where Anopheles sinensis was the principal vector, the malaria situation was highly unstable and local outbreaks took place from time to time. Meanwhile, the increase of the floating population brought more imported cases into Guangdong, Guangxi, Guizhou, Hunan, Fujian, Jiangxi, Chongqing, Shangdong, Zhejiang, and Shanghai, which accounted for 47%-100% of the cases reported in the P/M/A. Furthermore, because of the faultiness in the public health system and the network of the case reporting system, more malaria cases failed to be reported and it is therefore a challenge in implementing the program of malaria control and prevention.

China↗