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Since managed care differs from fee-for-service systems, practices should use this environment as an opportunity to examine their present data collection processes and think of the best way to integrate them into their daily operations. The power of marketing, financial, and quality-management data will be realized when managed care contract negotiations arise and when practices operate from a position of financial strength.
In summary, this is an exciting time in which materiel management, in conjunction with fiscal affairs, will be involved in just about all decisions affecting product use, cost, and management. It will be a period of many changes, and materiel managers must be willing to accept this and move forward into the future.
Strategies for redesign are necessary in successful managed care organizations as the member population grows and changes. This article presents a redesign project initiated by a managed care plan located in the Southwest region of the United States, where the rural frontier blends with metropolitan cities in a culturally diverse population. The focus of this project is the redesign of the Health Services department in which case management resides.
As a contracted provider for a popular health maintenance organization, you receive notice that it is converting its provider contracts to capitated reimbursement models. Reluctantly, you read to see how this change affects your practice. Are you positioned to accept "risk" for your patients? How will you manage your risk? Can you afford to terminate your relationship with this managed care organization and lose your patients to providers who are eager to expand their practice and patient base? This article presents an overview of capitation and ways to manage capitation while promoting quality care and outcomes for your patients.
BACKGROUND: The current study evaluated the efficacy of a 10-week, group-based, cognitive-behavioral stress management (CBSM) intervention relative to a half-day seminar in improving quality of life (QoL) among men who were treated for localized prostate carcinoma (PC) with either radical prostatectomy (RP) or radiation therapy. METHODS: Ninety-two men were assigned randomly to either the 10-week CBSM group intervention or a 1-day seminar (control group). The intervention was designed to improve QoL by helping participants to identify and effectively manage stressful experiences and was focused on the treatment-related sequelae of PC. RESULTS: A hierarchical regression model was used to predict postintervention QoL. The final model, including all predictors and relevant covariates (i.e., income, baseline QoL, ethnicity, and group condition), explained 62.1% of the variance in QoL scores. Group assignment was a significant predictor (beta = - 0.14; P = 0.03) of QoL after the 10-week intervention period, even after controlling for ethnicity, income, and baseline QoL. Post-hoc analyses revealed that individuals in the CBSM intervention condition showed significant improvements in QoL relative to men in the 1-day control seminar. Improved QoL was mediated by greater perceived stress-management skill. CONCLUSIONS: A 10-week cognitive-behavioral group intervention was effective in improving the QoL in men treated for PC, and these changes were associated significantly with intervention-associated increases in perceived stress-management skills.
Little research is available on the level of knowledge about ovarian cancer risk management options in women at increased risk for this disease. The study objectives were to evaluate this together with the information and ovarian cancer risk management preferences of high-risk women. One hundred and twenty-nine women were assessed after their attendance at one of six familial cancer clinics in relation to knowledge of surveillance and/or preventative strategies for reduction of ovarian cancer risk, preferences for particular strategies, and information preferences. Screening was selected by 57 (44%) women as the preferred risk management option. One hundred and five women (82%) indicated a wish for as much information as possible about ovarian cancer, including both good and bad outcomes and 114 (89%) reported a preference for sharing treatment decisions with their health professional. Participants' knowledge about ovarian cancer risk management options was significantly associated with educational levels (Z = -3.2, p=0.001) and whether or not ovarian cancer was included in the family history (Z = -2.3, p = 0.018). Findings from this present study indicate that women at increased risk of ovarian cancer who attend familial cancer clinics want as much information as possible about this disease and they want to be involved in the decision-making process. Women who reported a lower level of education (no post-school qualifications) may be most likely to benefit from additional educational strategies designed to supplement genetic counseling to improve their knowledge levels.
A biofeedback-based stress management training program was experimentally evaluated using populations of middle-level managers from a large corporation. The training program, once-weekly 1-hour sessions for 6 weeks, combined frontal and other site EMG biofeedback, progressive relaxation and breathing exercises, cognitive stress management, and generalization techniques. Control groups participated in either the assessment procedures only or the assessment procedures and six once-weekly discussions of stress and the job on both an individual (two sessions) and group (four sessions) basis. Significant effects were found in self-report measures, state and trait anxiety, experience of stress; in physiological measures, basal frontal EMG and frontal EMG during recovery from stress, and finger temperature; and in ratings of overall job performance. However, no consistent advantage for the training group or either control group was found. Several possible explanations for the failure of the biofeedback-based stress management training condition to achieve a consistent advantage over the control conditions are presented.
The local branches of the Russian Forestry Service, the leskhozy, were known for their efficiency and management skills in the Soviet era and were one of the very few community-based "Soviet-type" institutions to survive the transition. This article examines the role of the leskhozy in the new market economy. Our analysis is based on data from interviews with informants attached to the forestry sector in the Murmansk area. In some cases their knowledge of the leskhozy stretches back to the emergence of the system in 1947. Our principal finding is that the struggle to survive as a federal body in the current legal and economic climate is forcing the leskhozy to relegate sustainable forestry management, presumably their primary raison d'être, to the lower portions of their list of priorities. Several consequences result. There is a heightened incidence of illegal logging, and corruption informs the allocation of forest areas to private interests. Stumpage prices have plummeted as timber from subsidized commercial cutting (ostensibly sanitary cutting or thinning) has flooded the markets. The root cause of these tribulations lies with the market-based harvesting permit system. Its introduction in the 1990s did little to eliminate the self-seeking practices of the old Soviet forestry management hierarchies. In the free market, local forestry managers can turn their dual responsibilities to their own advantage inasmuch as they control the allocation of harvesting permits while at the same time controlling logging practices.
This paper describes the process of developing and testing a new questionnaire, Process Outcome Specific Measure (POSM), including an assessment of its content validity and reliability. The questionnaire was developed within the context of Trial Of Management of Borderline and Other Low-grade Abnormal smears (TOMBOLA) to assess the psychosocial impact of a low-grade abnormal cervical smear result and the subsequent management. A literature search, focus groups and thorough pre-testing involving experts and patients resulted in a short (15-item), easily completed and understood questionnaire. Questions address issues including cancer, health, fertility and sexual concerns. Repeatability was assessed in 110 TOMBOLA recruits using weighted k; all but one of the questions showed levels of reliability near to, or above, 0.5. Cronbach's standardised alpha was 0.73, indicating acceptable internal consistency. Each POSM item was correlated with the anxiety and depression sub-scales of the Hospital Anxiety Depression Scale (HADS). All except one of the questions correlated more highly with the total POSM score than with the HADS sub-scales thus indicating discriminant validity. The POSM will enable comparison of the alternative management policies for low-grade cervical smears in terms of the benefits (or otherwise) perceived by the women managed by these policies.
Coagulation abnormalities and bleeding disorders are frequently encountered in patients undergoing invasive procedures. These are of particular importance in the pain management setting where even small amounts of excessive bleeding can result in devastating complications. It is imperative that physicians treating those patients under-stand the basic concepts of coagulation and be able to identify and manage the common bleeding disorders. This article provides a brief overview of the coagulation system and describes the use of appropriate screening tests and management strategies to limit bleeding in pain management procedures.
The Moller-Murphy Symptom Management Assessment Tool (MM-SMAT) was developed to assist in the identification of psychiatric symptoms, health, and environmental variables, problems related to medication management and provide a common language for everyone involved in the ongoing management of neurobiological disorders to use in identifying the frequency, intensity, and duration of symptoms. The Murphy Wellness Model is a framework that provides insight into health, environment, and attitudes/behavior variables that became triggers of relapse. The combined use of this model and the MM-SMAT provides data to be used for anticipatory guidance of relapse management and the development of symptom-specific interventions.
UNLABELLED: This self-directed learning module highlights decision making in prosthetic management in pediatric and adult patients. This chapter reviews classification of congenital limb deficiency and management of congenital pediatric upper-extremity amputees. Differences in management of amputees of various ages from infancy to old age is discussed. Case examples are used to formulate prosthetic prescriptions for transradial limb deficiency as well as knee disarticulation and transtibial level amputations. Common prosthetic gait deviations and anticipated functional levels are evaluated. OVERALL ARTICLE OBJECTIVE: To discuss prosthetic prescription and management in congenital limb deficiency and acquired amputations for patients of various ages.
BACKGROUND: Absence of medical documents damages the quality of treatment and service. Despite the computerized medical folder, its use is still limited, and not all countries have a national health communications systems. That is why the patients are asked to bring with them the documents they hold. However, some patients lose the documents and others are uncooperative due to forgetfulness, and a lack of knowledge. OBJECTIVES: To examine how patients perceive, keep and manage medical documents. DESIGN: The research was conducted in the qualitative method. SETTINGS: A cardiology clinic, in a big medical center in Israel. PARTICIPANTS: A total of 28 patients suffering from ischemic heart disease and/or rhythm disorders. The sample was a convenience one, and were taken from the population visiting the Cardiology Clinic from May to October 2003. METHODS: Semi-structured interviews were held with the participants. The data were processed by means of content analysis. RESULTS: The findings indicate that, even though the participants expressed that it is the health system's responsibility to manage medical documents, most of them kept, and some even managed, their medical documents via a personal folder. By keeping documents and deciding to whom and when to show them the patient functions as a self-care manager. This made them more involved in their treatment and, they felt in control and empowered. CONCLUSION: Patient's attention to documents, as keeper and router, results in demonstrations of responsibility and involvement in treatment, consequently empowering the patient.
In Japan, the waste management practice is carried out in accordance with the Waste Disposal Law of 1970. The first rule of infectious waste management was regulated in 1992, and infectious wastes are defined as the waste materials generated in medical institutions as a result of medical care or research which contain pathogens that have the potential to transmit infectious diseases. Revised criteria for infectious waste management were promulgated by the Ministry of Environment in 2004. Infectious waste materials are divided into three categories: the form of waste; the place of waste generation; the kind of infectious diseases. A reduction of infectious waste is expected. We introduce a summary of the revised regulation of infectious waste management in this article.
OBJECTIVE: Our purpose was to determine the safety, efficacy, and costs of inpatient and outpatient management of symptomatic placenta previa. STUDY DESIGN: Fifty-three women with the initial diagnosis of placenta previa at 24 to 36 weeks' gestation who required hospitalization for vaginal bleeding were stabilized and then randomized to receive either inpatient or outpatient expectant management. Twenty-seven inpatients were placed at bed rest with minimal ambulation, received weekly corticosteroids until 32 weeks of gestation, and underwent ultrasonographic examination at 2-week intervals to assess fetal growth and placental location. Twenty-six outpatients were discharged home after > or = 72 hours of hospitalization. Each week they also received corticosteroids, until 32 weeks' gestation, and ultrasonographic evaluations. Outpatients with recurrent bleeding were readmitted for evaluation. All subjects who reached 36 weeks' gestation with persistent placenta previa underwent amniocentesis. When fetal lung maturity was present, cesarean delivery was electively performed. RESULTS: There were insignificant differences between inpatients and outpatients for mean age, parity, race, type of previa (complete or partial), number of prior vaginal bleeding episodes, and initial hemoglobin value. The mean estimated gestational age at enrollment was 29.1 +/- 3.1 (SD) weeks for inpatients and 29.9 +/- 3.1 weeks for outpatients. In eight patients the placenta was found to no longer cover the internal os by 36 weeks' gestation. There were seven patients in each group who did not complete the protocol for initial treatment assignment. The average estimated gestational age at delivery for the inpatients was 34.5 +/- 2.4 weeks and 34.6 +/- 2.3 weeks for the outpatients (p = 0.90), whereas the mean birth weights were 2413.7 +/- 642.7 gm and 2607.8 +/- 587.1 gm, respectively (p = 0.28). Thirty-three patients (62.3%) had recurrent episodes of bleeding, with 26 requiring expeditious cesarean delivery. Four (14.8%) inpatients and one (3.7%) outpatient required blood transfusion (p = 0.67). There was no difference in neonatal morbidity (defined as the presence of respiratory distress syndrome, intracranial hemorrhage, or culture-proved sepsis) between the two groups (relative risk 1.16, 95% confidence interval 0.66 to 2.02). There were no neonatal deaths. The mean number of maternal hospital days differed significantly between the two groups: inpatients required an average of 28.6 +/- 20.3 days and outpatients remained hospitalized for an average of 10.1 +/- 8.5 days (p < 0.0001). Cost analysis based on maternal hospital days reveals a net savings of +15,080 per patient if women with symptomatic placenta previa initially diagnosed before 37 weeks' gestation are treated as outpatients. CONCLUSIONS: For selected patients, outpatient management of symptomatic placenta previa appears to be an acceptable alternative to traditional conservative expectant inpatient management.
OBJECTIVE: To report the 5 years' experience of a postoperative pain service according to quality standards management. MATERIAL AND METHODS: The goals of pain treatment were determined from the description of the initial inquiries performed in 1994. Decrease in the postoperative pain for all the patients operated at the first and the third postoperative day, systematic evaluation of the pain, implementation of common therapeutic protocols, information and satisfaction of the patients, improvement in side effects' management, and a bearable managing cost. The deadline of these objectives was 1999. Patients were followed-up by a questionnaire at the third postoperative day, by verbal scale scoring every 4 h, by reporting techniques and analgesic drugs, and side effects. An audit of the nurses, was performed through a questionnaire in 1999. RESULTS: Four thousand sixty-eight patients were included in the audit over 5 years (1995-1999). Twelve objectives out of 15 were reached. Painful patients were less numerous, said themselves less painful, were more quickly relieved, and were satisfied by their management. The incidence of side effects was much lower than the figures of the literature. CONCLUSION: Pain control on mobilization, maintenance of a high quality continuous formation, and development of pain control process in the other surgical departments are the new goals in progress.
Intensive care unit (ICU) patients frequently suffer problems associated with both diarrhoea and constipation. Strategies to optimise the management of these conditions need to focus on improving the communication between staff and ensuring effective treatment is implemented. The team involved in this study developed a Bowel Management Protocol (BMP). The effect of this BMP on the documentation of assessment and management of diarrhoea and constipation was evaluated using a quasi-experimental research design. Data were collected via a retrospective audit of medical records. Two groups of patient records were randomly sampled. The records of 60 patients who were admitted to ICU in the 6 months before the introduction of the BMP were accessed together with the records of 60 patients admitted in the 6 months following the introduction of the BMP. Data were collected regarding patient demographics and the assessment and management of bowel function before and after BMP introduction. The results indicated that a BMP improved documentation of the assessment of bowel function. In addition, there was an improvement in the documentation of nursing intervention in the presence of constipation and diarrhoea. These results have to be interpreted with caution because, despite random sampling over two 6 month periods, there were statistically significant differences in age, length of stay, method of feeding and medical diagnosis between the two groups. Further research into the effectiveness of using a BMP is recommended.
Clinical practice and quality improvement (QI) guidelines for acute postoperative pain management have been developed to address the well-documented problem of undertreatment of postoperative pain. The Post-Operative Pain Management Quality Improvement Project (the POP Project) was initiated to determine whether an intervention designed to support hospitals in the development of QI efforts would lead to improvements in structures, processes, and outcomes consistent with recommended guidelines. A nationwide sample of 233 hospitals joined the project. The intervention consisted of written resource materials accompanied by support services that included an e-mail list server, a resource Web page, and assistance from POP Project staff via telephone. Data regarding critical structures, processes (practice patterns), and patient outcomes were collected at baseline before the intervention began and at follow-up 12 to 18 months later. Results showed a statistically significant increase from baseline (45%) to follow-up (72%) in the presence of structural elements that are critical to improving pain management. There were statistically significant improvements in practices including documented use of pain rating scales, decreased use of intramuscular opioids, and increased use of nonpharmacologic strategies. Patient survey data showed no change in pain outcomes. Evaluation data showed that 70% of hospitals were very or extremely satisfied with their participation in the POP Project and 90% of them planned to continue efforts to improve pain management after the POP Project ended. Further research is needed to determine how to translate the excellent results obtained for structure and process into meaningful outcomes for patients.