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PubMed1994

[Celebration of the 50th anniversary of the School of Public Health of the University of Chile].

The joined initiative of the University of Chile, the Health institutions, the Bacteriological Institute and the Rockefeller Foundation support allowed the creation of the School of Public Health. A group of skilled and talented young specialists gave rise to the School, as an expression of the need to refurbish the medical care of the forties. The aim of the School was to communicate the scientific basis of sanitary practice, to study national problems and to group people that can contribute to improve the health status of the country. During fifty years, the number of Chilean and foreign students expanded considerably. During these five decades the School has trained 1588 specialists (459 foreigners) in Public Health. The School was awarded by WHO in 1988 in recognition of its outstanding contributions to Public Health. It is difficult to make adequate decisions at the present time, due to the complexity of Chilean health situation, that is going through an epidemiological and demographic transition. A systematic effort to investigate and to train people in public health and health administration is mandatory. These are the principal tasks of the School, that maintains its fifty years tradition left by its founders.

Chile↗

PubMed2004

Priority setting in clinical nursing practice: literature review.

BACKGROUND: Time is a valuable resource. When nurses experience demands on their services which exceed their available time, then 'rationing' must occur. In clinical practice such rationing requires practitioners to set priorities for care. AIMS: The aim of this paper is establish what is currently known about priority setting in nursing, including how nurses set priorities and what factors influence this. METHOD: CINAHL, Medline, ASSIA, and PsychLit databases for the years 1982-2002 were searched, using the terms (clinical decision-making or problem-solving or planning) and (setting priorities or prioriti*). The publications found were used in a selective, descriptive review. FINDINGS: Priority setting is an important skill in nursing, and a skill deficit can have serious consequences for patients. Recent studies have suggested that it is a difficult skill for newly qualified nurses to acquire and may not be given sufficient attention in nurse education. Priority setting can be defined as the ordering of nursing problems using notions of urgency and/or importance, in order to establish a preferential order for nursing actions. A number of factors that may impact on priority setting have been identified in the literature. These include: the expertise of the nurse; the patient's condition; the availability of resources; ward organization; philosophies and models of care; the nurse-patient relationship; and the cognitive strategy used by the nurse to set priorities. However, very little empirical work has been conducted in this area. CONCLUSIONS: Further study of priority setting in a range of clinical practice settings is necessary. This could inform both practice and education, promote better use of limited resources and maximize patient outcomes.

Attitude of Health Personnel↗

PubMed1986

Health Services Research and Development: the Veterans Administration Program.

Health expenditures are rising inexorably; health status shows relatively little gain; technological possibilities are outstripping our ability or willingness to provide a commensurate level of resources. Clinical and administrative managers face increasingly difficult choices among alternative interventions in attempting to resolve these problems. If health services research is to succeed as a tool for assisting these decisions, clinicians, administrators, and researchers must view it as an integral part of management. This paper describes this concept of health services research and its implementation by the VA HSR&D Service, results from 1981 to date, and future directions. Four programs implement the Service's system to make relevant, valid information accessible to VA staff who can use it to improve veterans' health care: Investigator-Initiated Research (IIR) Program; HSR&D Field Program, which implements the Service's mission in various local areas VA-wide; Special Projects Program, responsive to system-wide issues, including technology assessment and transfer; and Resources Program, the Service's own management system. The Service's impact on improving veterans health care is already apparent. However, the true value of the HSR&D system will become apparent only in the 1990s, after the capacity for conducting health services research has been built and integrated fully with clinical and administrative practice. The VA, the nation's largest health care system, has a unique opportunity to demonstrate how health services research can improve health care.

Aged↗

PubMed1992

Medical futility. Committee on Bioethical Issues of the Medical Society of the State of New York.

The term futile is used in many different ways. It is therefore difficult to decide whether a procedure or treatment such as CPR or hemodialysis or blood transfusion would be futile in a given case. The AMA's guidelines on the appropriate use of DNR orders state that DNR decisions should be made openly. Institutions should have policies and physicians should elicit the patient's preferences about CPR. For physicians, the question is no longer whether we should discuss DNR orders with our patients; instead, the issue is how to do so with compassion and caring. Physicians should share with patients their judgment about what medicine can and cannot do. Then physicians must "make decisions about when to withhold or limit resuscitation openly" in honest and trusting conversation between doctor and patient. Often CPR is an exercise in futility. The medical profession should be vested with the authority to make futility decisions if they are the product of open discussion and shared deliberation between physician and patient, family, or surrogate. Rationing, triage, and medical futility in relation to AIDS patients require careful deliberation and consideration. What was considered medically futile five years ago for an AIDS patient may be appropriate care nowadays. The need for appropriate use or non-use of life-sustaining therapy for the elderly, the terminally ill, patients with AIDS and other incurable illnesses is evident to patients, health care providers, policy makers, and the public. CPR should only be administered if it is expected to confer lasting benefit to the patient. However, if 10% of elderly patients benefit from CPR in the case of out-of-hospital cardiac arrest, how can one consider this procedure futile? Although communication between physician and patient about difficult treatment limitation decisions has markedly improved in recent years, it remains a problem, largely because open dialogue with patients and families about futility is a demanding emotional and intellectual task. The medical profession is charged with setting standards for the proper implementation of judgments regarding futility.(ABSTRACT TRUNCATED AT 250 WORDS)

Cardiopulmonary Resuscitation↗

PubMed2001

A consumer perspective on informed consent and third-party issues.

Our two children were diagnosed with a rare genetic disorder, which led us to establish a research foundation. This led to in-depth consideration of issues surrounding informed consent from a consumer perspective. Third-party issues arose as central to the formulation of ethical policy in the establishment of a blood and tissue bank and an epidemiologic study. We suggest that a number of myths--privacy is possible, samples can be stripped of identifiers, humans are subjects, voluntary informed consent is attainable, genetics is about the individual only, genetic information is different than other medical information, research is altruistic, the public will learn truths about genetic research via media, and research is culturally competent--make it difficult to resolve the issues intrinsic to informed consent. A number of important elements could make policy decisions less complicated. These include conducting culturally competent research; conveying noncoercive hope, not hype; contacting the voluntary informant only; asking the informant to extend contact to other family members; requiring a comprehensive informed consent process for all contacted; and engaging in state-of-the-art data protections. There is a need for a "Genomic Hippocratic Oath," creating an ethical basis for research similar to the one vowed by health care professionals. Establishing ethical policies as a result of the collaboration of policy makers, researchers, and consumers will allow research to progress ethically at a rapid rate. If regulations are oppressive, they will thwart research; if they are too lenient, participants will not receive protections needed to participate safely.

Child↗

PubMed1979

Improving the quality of life for the elderly.

The United States Senator from Maryland, as speaker at the Awards luncheon of the American Geriatrics Society (Washington meeting), presented his views on priorities in various health programs for the elderly, and asked for the Society's cooperation in making some of the difficult decisions that lie ahead. An important item is cost-effectiveness. These decisions will affect every discipline involved in geriatrics, and have an important bearing upon the quality of life for the elderly. A better understanding is needed of the interaction between aging and disease, and the use of preventive measures.

Aged↗

PubMedDate not supplied

The SAGE-PAGE trial: do family genograms make a difference?

BACKGROUND: Despite enthusiastic promotion of family genograms, the impact of routine use of this tool on clinical practice has not been systematically examined. The present study investigated whether doing a genogram, or having one available, makes physicians more sensitive to psychosocial issues or in other ways affects the physician-patient relationship or the process of clinical care. METHODS: In a randomized clinical trial, patients visiting 5 physicians at an academic family practice center (n = 189) received a physician-administered genogram (PAGE); a self-administered genogram (SAGE), which the patient completed before seeing the physician; or no genogram. A fourth (baseline) group was tested without genograms prior to the randomized trial. RESULTS: Analyses of patients' and physicians' postencounter questionnaires showed no impact of genograms on how physicians think about and deal with clinical problems or how patients view the encounter with their physicians. Compared with control groups, neither patient- nor physician-administered genograms increased the physician's (self-defined) understanding of the patient or the importance the physician attached to psychosocial issues in the case. A positive finding was that physicians considered genograms more relevant when they did them themselves. On the other hand, physician-administered genograms also increased the length of the encounter and were substantially less complete (conveying less information) than genograms completed by patients. CONCLUSIONS: THe results leave open the possibility that genograms do make a difference when used routinely by residents or experts or in difficult cases when family assessment is indicated. While enthusiasm about genogram applications in family medicine is understandable, the clinical utility of this tool remains to be demonstrated scientifically.

Adolescent↗

PubMed1992

Crucial questions for physiotherapy in Finland.

When planning for health services, questions of production and distribution as well as cost and quality are key issues for health planners and decision makers. The lack of available objective data often makes this work difficult. This paper presents recent efforts in Finland to improve the collection of information needed for planning in the field of physiotherapy.

Costs and Cost Analysis↗

PubMedDate not supplied

Health and the welfare of U.S. business.

Business leaders continue to blame the skyrocketing cost of health care for jeopardizing the global competitiveness of U.S. industries, and they continue to turn to Washington for the solution. Yet after a study of 16 countries, Wharton researchers David Brailer and R. Lawrence Van Horn have discovered that health care costs do not directly hinder U.S. competitiveness. Their conclusion: there is indeed a health care crisis in the United States as well as a competitiveness crisis. But the two are unrelated, and confusing them makes it difficult to solve either one. The real problem, according to the authors, is the hands-off approach that employers typically adopt when it comes to health care. No matter how Washington responds to the health care crisis, employers must explore their own role in ensuring the health of their work force. And they must realize that their role can be a strategic one. Instead of containing costs by fine-tuning benefits packages, companies can control costs and improve health care delivery by treating health care like any other crucial component of production. Brailer and Van Horn propose three strategies for managing health care delivery: First, companies must intervene in the supply side of the health care market. This may mean creating a clinic alone or with other companies, or joining with other companies to procure health care. Second, companies need to translate corporate health benefits into the most cost-effective set of services at the local level. Finally, companies must encourage and educate employees to participate in decisions regarding health care delivery.(ABSTRACT TRUNCATED AT 250 WORDS)

Costs and Cost Analysis↗

PubMed2001

Addressing uncertainty in medical cost-effectiveness analysis implications of expected utility maximization for methods to perform sensitivity analysis and the use of cost-effectiveness analysis to set priorities for medical research.

This paper examines the objectives for performing sensitivity analysis in medical cost-effectiveness analysis and the implications of expected utility maximization for methods to perform such analyses. The analysis suggests specific approaches for optimal decision making under uncertainty and specifying such decisions for subgroups based on the ratio of expected costs to expected benefits, and for valuing research using value of information calculations. Though ideal value of information calculations may be difficult, certain approaches with less stringent data requirements may bound the value of information. These approaches suggest methods by which the vast cost-effectiveness literature may help inform priorities for medical research.

Cost-Benefit Analysis↗

PubMed2003

Decision support at the point of care: challenges in knowledge representation, management, and patient-specific access.

Many applications in a clinical information system can benefit from the incorporation of medical knowledge to provide patient-specific, point-of-care decision support. These include computer-based provider order entry, referral, clinical result interpretation, consultation, adverse event monitoring, scheduling, shared patient-doctor decision-making, and generation of alerts and reminders, among others. To be executable, knowledge must be represented in the form of rules, constraints, calculations, guidelines, and other logical/algorithmic formats. The main difficulty is that the integration of such knowledge into clinical applications, when it occurs, tends to be very system- and application-specific, often encoded in a programming language, or even in the formating specifications of a user interaction display. Also, the data references and services invoked are highly dependent on the system/platform and electronic medical record implementation. This makes it difficult and time-consuming to encode authoritative evidence-based knowledge, severely limits the ability to disseminate and share successes, and hampers efforts to review and update the logic as medical knowledge changes. Solutions to this problem involve the development of standards-based representations for medical knowledge, and tools for authoring/editing, dissemination, adaptation to local environments, and execution. Numerous approaches are being pursued, all of which will be described in this presentation.

Decision Support Systems, Clinical↗

PubMed2004

Allocation or misallocation of limited medical resources.

Very small premature babies are now kept in neonatal intensive care units for many months to give them a chance at near normal life, but at a cost of up to dollars 1 million. Is that a proper allocation of our finite medical resources (personnel, equipment, supplies, and other necessities) for premies? Or is such action a misallocation of these resources? Both sides of the argument have positive and negative merit. A final philosophical statement is that each human created in the image of God has supreme value. It is it the obligation of fellow humans and society in general to preserve and dignify human life and to care for the total needs of individual citizens to enable them to be healthy and productive members of society. This general principle should help individual physicians make proper microallocation life and death decisions for individual patients and assist governmental bodies responsible for making macroallocation decisions concerning the short- and long-term needs and priorities of the population as a whole. All such decisions should be guided by the basic ethical principles of beneficence, nonmaleficence, autonomy, and justice. However, these principles may at times conflict. For example, if the autonomous rights of the patient conflict with the justice appeals of the community or if beneficence to an individual patient conflict with the needs of another patient, can we deny health care services? By what criteria (merit, potential, effort, achievement, age)? These are difficult if not impossible questions to answer, but they pertain to the topic of this commentary on the allocation of limited medical resources, which is meant to raise the sensitivity of the reader to the complexity of the problem and to raise ethical questions, which are not easily answered or dealt with.

Health Care Rationing↗

PubMedDate not supplied

Ethical issues in long-term care for the elderly.

During the past 20 years there has been a wealth of literature on various aspects of ethical decision-making. The ethical dilemmas which confront health professionals become more and more complex as knowledge and technology expand. Professionals have more and more effect on human lives. As research provides professionals with more intervention tools, questions arise about "quality of life" and "who has the right to make life and death decisions." This paper examines the potential for ethical difficulties in long-term care settings for the elderly. Given the necessity for a multidisciplinary approach to geriatric care, a variety of professionals are involved in the delivery of services in multiple settings. For the purpose of this paper, these professionals are referred to as "health professionals" since we are defining health as physical, mental, and social well-being. Case examples will be used to illustrate potential issues when health professionals intervene with elderly persons who are in difficult situations. To provide a context, five codes of ethics (ie, health educators, social workers, physicians, clinical psychologists and nurses) will be examined. Each of these health profesionals is involved in service provision to an elderly client/patient or his family in the area of long-term care. These codes will be examined in light of their historic roots.

Aged↗

PubMed1995

NLRB to issue landmark decision on nurse practitioners.

The National Labor Relations Board is poised to issue a decision in Saints Memorial Medical Center. The narrow legal issue to be decided is with which of the eight acute care bargaining units nurse practitioners should be placed. The practical consequences of the decision, however, will be profound. The NLRB will determine, among other matters, the ease or difficulty of organizing nurse practitioners into labor organizations. Numerous friend-of-the-court briefs have been filed by various health care labor organizations, employer groups, and professional groups, taking contrary positions. The authors favor placement of the nurse practitioners and other advanced practice nurses within the physicians bargaining unit, because as a practical matter, this will lead to the creation of more nurse practitioner positions. Such a ruling, however, will make it more difficult to organize nurse practitioners.

Acute Disease↗

PubMed1997

Breast cancer patients' attitudes about rationing postlumpectomy radiation therapy: applicability of trade-off methods to policy-making.

PURPOSE: Along with evidence, clinical policies must take patients' values into account. Particularly where evidence is limited and where assumptions of utility-maximizing behavior may not be valid, new methods such as trade-off techniques (TOTs), which allow elicitation of patients' treatment alternatives, might be useful in policy formulation. We used TOTs to assess breast cancer patients' attitudes toward two clinical policies designed to ration adjuvant postlumpectomy breast radiation therapy. METHODS: Cross-sectional interviews were performed in a tertiary cancer center. A total of 102 patients were presented with information about the side effects and benefits associated with two hypothetical decisions: (1) willingness to receive treatment elsewhere to shorten the wait for radiation therapy, and (2) foregoing radiation therapy in the face of small marginal benefits. For each scenario, a TOT was used to identify the maximal acceptable wait time (MAWT) for therapy and the benefit threshold at which the patient would forego therapy. Associations of clinical and demographic factors with these decisions were determined by regression analysis. RESULTS: Patients would be willing to wait, on average, 7 weeks before wanting to leave their city for radiation therapy, less than the 13-week delay our patients actually faced. Older patients were less willing to wait (P = .013); 46% of patients would not give up radiation therapy, even in the face of no stated benefit. Willingness to give up radiation therapy was predicted by willingness to accept delay (odds ratio [OR], 1.84; 95% confidence interval [CI], 1.05 to 3.37) and being employed (OR, 2.61; 95% CI, 1.08 to 6.54). Patients with larger tumors were less willing to give up radiation therapy (OR, 0.57; 95% CI, 0.31 to 0.97). CONCLUSION: Even in difficult decisions such as rationing postlumpectomy breast cancer radiation therapy, TOTs can inform policy formulation by indicating the distributions of patients' preferences.

Adult↗

PubMed1986

Nursing home placement and the demented patient. A case presentation and ethical analysis.

The decision to seek nursing home placement will be faced with increasing frequency as the population over age 65 continues to grow. Although this is a difficult juncture under any circumstances, the ethical issues accompanying such a move for persons of diminished competence are unusually complex and require involvement of many concerned parties. In a typical case presentation, the social context informing these decisions is described, including bias against the aged, perceptions of scarce resources in health care, and the problematic role of the courts. The perspectives and moral obligations of the patient, family, and health professionals are discussed and contrasted to clarify the sometimes conflicting roles and needs of those three parties. A stepwise process of decision making before nursing home placement is offered in an effort to choose the least restrictive alternative for the patient while respecting the needs of concerned persons.

Alzheimer Disease↗

PubMed2003

[Adopted children: risk factors and neuropsychological problems].

In recent years there has been a striking increase in the number of transnational adoptions in our country, which follows the trend already observed in other developed European countries. Major contributing factors to this phenomenon have been the improvements in socioeconomic conditions in our country, the drop in the birth rate, with the corresponding decrease in the number of children available for adoption, and the disappearance of orphanages. This growing demand can be met by developing countries, in which the birth rate is still high and there are only limited chances of being able to maintain offspring. The children that are adopted come mainly from countries in Central and South America, Eastern Europe and Asia. Pathologies that can be expected in adopted children include general paediatric conditions, especially infections (which are often autochthonous ailments in their own country) and malnutrition, as well as neuropsychological and developmental disorders, such as psychomotor retardation, conduct and behavioural disorders, which sometimes stem from conflicts arising in the process of adaptation, communication problems, which occasionally reflect an autistic like disorder, and the problems deriving from the circumstances that condition the donation of the child for adoption (perinatal pathology, maternal drug addiction and withdrawal symptoms, maternal psychopathology.). The pathology, history and prognosis of the adopted child depend on several different factors that act in an accumulative fashion. The country of origin plays a decisive role in the type of pathology, according to the level of the health care system that exists there, the existence of adoption programmes that are regulated by law, etc. The child's age at adoption marks the difference in the optimisation of their development, if they have early access to a stable family unit. Having stayed in institutions and the length of time spent there is a risk factor for presenting a neuropsychological pathology. On many occasions the scarce information available about the child's medical history makes it more difficult to anticipate the appearance of certain problems. The existence of social risk factors in the biological families is a conditioning factor in increased morbidity. We describe a short series of adopted patients who were attended in our Neuropaediatric clinic, and we analyse the above mentioned conditioning variables and the most frequent pathologies.

Adolescent↗

PubMed1999

Characteristics of peer reviewed clinical medicine journals.

Many variations exist in editorial peer review practices in clinical medicine journals. These practices will become more crucial as medical journals make more of their contents available via the World Wide Web. This paper explores five fundamental dimensions of editorial peer review variations: (1) the extent to which manuscripts are subjected to peer review; (2) the sequence of decision points in the peer review process; (3) blinding practices; (4) acceptance rates for submitted manuscripts; and (5) guidelines stating editors' expectations of reviewers. Variations in editorial peer review practices make it difficult to define a "peer reviewed journal" in clinical medicine. Research in this relatively new area of inquiry has not established the relative strengths of each variation in relation to a journal's quality.

Clinical Medicine↗