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PubMed2006

Accessing government subsidized specialist orthodontic services in Western Australia.

BACKGROUND: In Australia there is growing demand for dental services. This leads to more pressure on the oral health service providers, and in particular government subsidized dental care. Against this backdrop it is important that government dental services (rationed to health care cardholders) are provided equitably on a basis of need, not access. The primary hypothesis investigated in this study was that there would be an even distribution of patients referred for government subsidized orthodontic care across Western Australia when regionally adjusted for socio-economic status. METHODS: Data were obtained as a de-identified waiting list for orthodontic treatment at The University of Western Australia. The data included all patients on the orthodontic waiting list as at December 2003. RESULTS: Significant differences between ARIA categories were detected when all waiting list entries were distributed. However, the trend was towards more entries (adjusted for population) in highly accessible areas. It was found that people from relatively wealthy areas tended to be more likely to be on the waiting list than those from more disadvantaged regions. CONCLUSION: In summary, the results of this study indicate that there is an uneven distribution of demand for orthodontics waiting list positions across Western Australian postcode areas by remoteness (ARIA) and by socio-economic disadvantage (IRSD). The results suggest that demand for subsidized orthodontic care may be influenced by the general demand for treatment of that region and not on what would be expected to be an even need for treatment across all health care cardholders.

Adolescent↗

PubMed2002

The Improving Primary Care of African Americans with Diabetes (IPCAAD) project: rationale and design.

African Americans have an increased burden of both diabetes and diabetes complications. Since many patients have high glucose levels novel interventions are needed, especially for urban patients with limited resources. In the Grady Diabetes Clinic in Atlanta, a stepped care strategy improves metabolic control. However, most diabetes patients do not receive specialized care. We will attempt to translate diabetes clinic approaches to the primary care setting by implementing a novel partnership between specialists and generalists. We hypothesize that endocrinologist-supported strategies aimed at providers will result in effective diabetes management in primary care sites, and the Improving Primary Care of African Americans with Diabetes project will test this hypothesis in a major randomized, controlled trial involving over 2000 patients. Physicians in Grady Medical Clinic units will receive (1) usual care, (2) computerized reminders that recommend individualized changes in therapy and/or (3) directed discussion by endocrinologists providing feedback on performance. We will measure outcomes related to both microvascular disease (HbA1c, which reflects average glucose levels over an approximately 2-month period) and macrovascular disease (blood pressure and lipids) and assess provider performance as well. We will compare two readily generalizable program interventions that should delineate approaches effective in a primary care setting as needed to improve care and prevent complications in urban African Americans with type 2 diabetes.

Black People↗

PubMed1993

Effectiveness of antenatal care: a population based study.

OBJECTIVE: To analyse the effectiveness of antenatal care as a screening for nonsymptomatic disease and obstetrical risk conditions. DESIGN: Programme evaluation of antenatal care in a geographically based cohort. SETTING: Routine clinical practice in primary and specialist level of health care without intervention. SUBJECTS: One thousand nine hundred and eight women residing in one Norwegian county giving birth during a 12 month period, 1988 to 1989. OUTCOME MEASURES: The detection rates at the time of delivery, for women with five conditions: twin pregnancies, placenta praevia, breech presentation, small for gestational age (SGA) and pre-eclampsia. RESULTS: Two hundred and ninety-two women had one or more of the actual conditions, 124 (42%) had been diagnosed at the time of the delivery. The detection rate for SGA was remarkably low (14%). The detection rates for pre-eclampsia (75%), breech presentation (69%), placenta praevia (57%) and twin pregnancies (94%) were in the same range as results reported in the literature. The number of false positive antenatal diagnosis was insignificant. CONCLUSIONS: Assessing the effectiveness of antenatal diagnosis of growth retardation is connected with major unsolved methodological problems. Clinical management of such cases may be better than indicated by the results based on the ultimate SGA classification. For important obstetrical conditions this study describes an applicable method for practical evaluation of the effectiveness of antenatal care. Areas where care could be improved are demonstrated.

Adolescent↗

PubMed1997

A comparison of three methods for estimating the requirements for medical specialists: the case of otolaryngologists.

OBJECTIVE: To compare three methods of computing the national requirements for otolaryngologists in 1994 and 2010. DATA SOURCES: Three large HMOs, a Delphi panel, the Bureau of Health Professions (BHPr), and published sources. STUDY DESIGN: Three established methods of computing requirements for otolaryngologists were compared: managed care, demand-utilization, and adjusted needs assessment. Under the managed care model, a published method based on reviewing staffing patterns in HMOs was modified to estimate the number of otolaryngologists. We obtained from BHPr estimates of work force projections from their demand model. To estimate the adjusted needs model, we convened a Delphi panel of otolaryngologists using the methodology developed by the Graduate Medical Education National Advisory Committee (GMENAC). DATA COLLECTION/EXTRACTION METHODS: Not applicable. PRINCIPAL FINDINGS: Wide variation in the estimated number of otolaryngologists required occurred across the three methods. Within each model it was possible to alter the requirements for otolaryngologists significantly by changing one or more of the key assumptions. The managed care model has a potential to obtain the most reliable estimates because it reflects actual staffing patterns in institutions that are attempting to use physicians efficiently. CONCLUSIONS: Estimates of work force requirements can vary considerably if one or more assumptions are changed. In order for the managed care approach to be useful for actual decision making concerning the appropriate number of otolaryngologists required, additional research on the methodology used to extrapolate the results to the general population is necessary.

Data Interpretation, Statistical↗

PubMed1998

High-billing general practitioners and family physicians in Ontario: how do they do it? An analysis of practice patterns of GP/FPs with annual billings over $400,000.

BACKGROUND: To better understand the reasons why some fee-for-service physicians have high billing levels, the authors compared the practice and demographic characteristics of general practitioners and family physicians (GP/FPs) who submitted over $400,000 in annual Ontario Health Insurance Plan (OHIP) fee-for-service claims in 1994-95 with those of GP/FPs who billed between $35,000 and $400,000. METHODS: The authors describe the OHIP billing and physician characteristic data for fiscal year 1994-95. They used multivariate logistic regression to determine factors independently associated with high billing status. RESULTS: A total of 219 GP/FPs (2.5% of the GP/FPs in Ontario) billed over $400,000 in 1994-95. Of these, 14 had billing patterns similar to those of specialists, and 27 billed predominantly for diagnostic and therapeutic procedures (particularly physiotherapy). The remaining 178 (81.3%) billed for a mix of services similar to that of other GP/FPs but on average had 2.6 times the volume of patient assessments and a greater share of their total billings derived from diagnostic and therapeutic procedures (9.1% v. 5.6%). Multivariate analysis indicated that these high-volume GP/FPs were less likely than GP/FPs who billed between $35,000 and $400,000 to be 60 years of age or older (odds ratio [OR] 0.09, p < 0.05) and female (OR 0.21) and were more likely to be foreign graduates (OR 1.85) and practising in a region with low physician supply (OR 0.45 for each increase of 1 physician per 1000 population). Metropolitan Toronto was an outlier to the latter relation and was more likely to have high-volume GP/FPs (OR 16.89). INTERPRETATION: High-billing GP/FPs attained their high billing levels by maintaining large numbers of patient visits and by performing procedures. Further research is needed to determine the time spent per patient and the quality of care delivered by these physicians as well as the appropriateness of the procedures that they perform.

Adult↗

PubMed2025

Leveraging Pharmacy Education through a Train-the-Trainer Model to Enhance Breast Cancer Literacy in Rural Communities.

Rural versus urban communities experience disproportionate challenges in breast cancer outcomes, with higher breast cancer mortality and later stage disease presentation, despite similar diagnosis rates. These disparities are driven by structural barriers, including rural hospital closures, transportation difficulties, and limited access to oncology specialists. This study evaluated a train-the-trainer program designed to equip PharmD students located at a pharmacy school in a rural county in South Carolina with breast cancer education training, leveraging the pharmacists' position as accessible healthcare professionals in rural communities. Training focused on breast cancer risk factors, prevention, screening, genetics, staging, and treatment options. Effectiveness was measured through pre- and post-workshop confidence surveys and knowledge assessments. Results showed significant improvement in student confidence across educational domains, with average scores increasing from 6.30 to 8.59 (p < 0.0001). Understanding of screening guidelines (mean difference: 4.30; p-value: < .0001) and target therapy options showed the greatest improvement (mean difference: 3.65; p-value: < .0001), while knowledge of BRCA gene inheritance showed the smallest change (mean difference: 0.369; p-value: ns), suggesting some pre-existing awareness but limited understanding of its clinical applications. Overall, this pilot program demonstrates how pharmacy education can address healthcare disparities in rural communities. By preparing pharmacists to deliver accurate breast cancer education and to increase rural patient agency, this model creates a sustainable approach to improving health literacy in medically underserved areas. Future research could further expand this model to include diverse healthcare professionals and incorporate long-term impact assessments in community settings.

Humans↗

PubMed2000

A comparison of two methods for estimating the health care costs of epilepsy.

PURPOSE: Previous studies have estimated medical care costs of epilepsy by applying unit costs to estimated utilization or by summing costs for (a) ambulatory care and hospitalizations coded as epilepsy and (b) procedures and drugs specifically associated with the diagnosis or treatment of epilepsy. These methods may underestimate the cost of medical care for epilepsy. Two methods for estimating the medical care costs of epilepsy ("epilepsy-attributable cost method" and "case-control cost method") were compared. METHODS: The study population was 655 individuals with an epilepsy diagnosis enrolled in a managed care plan in the southwestern United States. The epilepsy-attributable costs were determined by summing costs for inpatient and outpatient encounters coded as epilepsy, procedures for the diagnosis or treatment of epilepsy, and drugs used to treat epilepsy. The case-control method determined costs by calculating the difference in total costs between cases and 1,965 age- and gender-matched controls. RESULTS: The case-control epilepsy costs were $2,923 per case compared with epilepsy-attributable costs of $1,335 per case. The case-control method found statistically significant differences in costs between cases and controls for inpatient care, prescription drugs, and 8 of 11 categories of outpatient care. The largest contributors to the discrepancy between estimates were inpatient care, emergency department care, laboratory tests, and "other specialist" care. CONCLUSIONS: Epilepsy-attributable costs accounted for only 46% of the total difference in costs between epilepsy cases and controls. Persons with epilepsy use more medical services than controls, but a substantial portion of this care is not coded to epilepsy.

Adolescent↗

PubMed1984

Visions for the future.

I have discussed, from my vantage point as a public health specialist, areas for emphasis in control and prevention of nosocomial infections. Surveillance is the key to all control and prevention programs. With the constraints of resources and increasing responsibilities, infection control personnel have to be innovative, inventive, and imaginative in their approach to surveillance. The principles of epidemiology may be overlooked in the rush to perform. Epidemiology is a valuable science; it is being applied to an increasing number of problems inherent to hospitals. The community and the hospital are closely related in regard to nosocomial infections. There is constant two-way traffic of both people and bugs that can be properly addressed through cooperative action. The international arena may not have a great impact on each of you, but collectively, APIC has much to offer to developing countries. We should support with actions those countries that are becoming concerned over nosocomial infections. Regardless of your own priorities, there will be new and significant challenges to all practitioners of infection control, challenges related to new and currently unidentified problems, and unfortunately, fewer resources with which to meet the challenges. I congratulate APIC, its officers, and members on all you have done to focus attention and intellect on the problem of nosocomial infections. A humble beginning has been extremely productive by all possible criteria, especially by imitation, which is "the highest form of praise."

Community-Institutional Relations↗

PubMed1989

Health care provider and contraceptive care setting: the relationship to contraceptive behavior.

This study examines contraceptive delivery characteristics and their association with contraceptive behavior. Data were collected in telephone interviews from a national sample of 1057 women who were using female contraceptives. The overwhelming majority of the sample obtained contraceptive services from gynecologists and other physician specialists and were seen in private facilities. Whereas nearly half of the providers recommended use of specific methods, only one-fourth discouraged use of particular methods. The pill was both the most frequently recommended and most commonly discouraged method. With regards to the provision of contraceptive information, practitioners were most likely to discuss the effectiveness of a method. In three of the four categories examined, a higher percentage of non-MDs than MDs gave information to their patients. Although the majority of women reported they were satisfied with the quality of care, mean satisfaction ratings were higher for female providers compared to male providers.

Adolescent↗

PubMed2005

The feasibility and acceptability of a specialist health and social care team for the promotion of health and independence in 'at risk' older adults.

Population ageing, escalating costs in pensions, health-care and long-term care have prompted a new policy agenda for active ageing and quality of life in old age across the European Union and other developed countries. In England, the National Service Framework for Older People (NSF OP) explicitly demands for the first time that the NHS and local authorities, in partnership, agree programmes to promote health ageing and to prevent disease in older people. These programmes are expected to improve access for older people to mainstream health promotion services and also to develop multiagency initiatives to promote health, independence and well-being in old age. This paper describes the evaluation of one interagency project team established to test out mechanisms for addressing health promotion for older people through primary care. A mixed methodology was used to understand the processes of service development, the impact of the team's intervention, and the primary and secondary outcomes for older people. The project demonstrated that multi-agency partnerships have the potential to improve the quality of the lives of older people deemed 'at risk' by their general practitioners, particularly through income generation but also in the identification of medical problems such as unrecognised hypertension, hearing loss and visual loss. It also offered some key learning points for other multi-agency groups developing similar services.

Activities of Daily Living↗

PubMed2002

Alcohol use in South Africa: findings from the South African Community Epidemiology Network on Drug use (SACENDU) Project.

OBJECTIVE: To provide community-level public health surveillance on alcohol misuse in South Africa and the associated negative consequences. METHOD: A descriptive, epidemiological study of alcohol use based on data gathered biannually from multiple sources over 4 years, including specialist treatment centers, trauma units, mortuaries, psychiatric facilities, and surveys of school students and arrestees. Networks were set up in five sentinel sites to facilitate the collection, interpretation and dissemination of data. RESULTS: Indicators point to the widespread misuse of alcohol. Alcohol consistently dominates the demand for substance use disorders treatment services. In the second half of 2000, 51.1% (Cape Town) to 77.0% (Mpumalanga) of patients reported alcohol as their primary substance of abuse. A high proportion of patients in trauma units tested positive for alcohol in 2000, ranging from 40.3% (Durban) to 91.8% (Port Elizabeth). Similarly, a high proportion of mortality cases tested positive for alcohol, ranging from 40.3% (Durban) to 67.2% (Port Elizabeth). Although treatment demand is dominated by men and older persons, alcohol misuse occurs among all sectors. School surveys reflect harmful drinking patterns among students, with 53.3% and 36.5% of male students in Durban and Cape Town, respectively, reporting heavy-drinking episodes by Grade 11. DISCUSSION: Alcohol misuse has a number of implications for public health policy, such as the need to develop protocols for the management of alcohol-positive patients in trauma units and to target prevention programs at heavy drinking by young people. Further monitoring of alcohol misuse and its associated negative consequences is required.

Adult↗

PubMedDate not supplied

Barriers associated with the delivery of Medicare-reimbursed diabetes self-management education.

PURPOSE: The purpose of this study was to explore the barriers that practitioners face in providing diabetes self-management education (DSME) to Medicare beneficiaries, with a special focus on barriers faced by rural providers. METHODS: Using an e-mail survey, Diabetes Control Program Coordinators (DCPCs) in all US states were asked 3 open-ended questions to understand problems with obtaining American Diabetes Association (ADA) recognition for Medicare reimbursement, differences in obtaining ADA recognition by rural and urban facilities, and facility-level barriers to providing DSME to Medicare patients. Using a mail survey administered to half of ADA-recognized diabetes education centers (DECs), information was collected about perceived barriers to providing DSME in all areas and rural areas. RESULTS: Most DCPCs believed it was more difficult for rural providers to obtain ADA recognition than for urban providers; the largest barriers were costs and reporting requirements. The top barriers for rural providers mentioned by DCPCs were the shortage of designated specialists, fewer resources, and high application fees for ADA recognition. Barriers identified by DEC respondents facing rural providers include staffing/institutional support, amount of Medicare reimbursement, lack of hours covered, and transportation. DEC respondents providing care in urban areas only were more likely to perceive barriers to providing diabetes education in rural areas than were rural providers. CONCLUSIONS: Barriers to DSME are perceived to be higher for rural providers than urban providers. Urban providers perceived that many barriers to DSME are greater for rural providers. The ADA application process is perceived as expensive and laborious. Most respondents perceived Medicare reimbursement for DSME as inadequate.

Aged↗

PubMed2000

Critical care bug team: a multidisciplinary team approach to reducing ventilator-associated pneumonia.

BACKGROUND: Ventilator-associated pneumonia rates in the medical-surgical intensive care unit first exceeded the 90th percentile in September 1997 and were significantly (P <.05) higher than National Nosocomial Infections Surveillance System pooled mean data. In January 1998, a multidisciplinary "Critical Care Bug Team" was developed by the Infection Control Committee to review 1997 National Nosocomial Infections Surveillance System data for four adult intensive care units in a 583-bed tertiary care hospital. METHODS: Membership included clinical nurse specialists, a dietitian, a pharmacist, a respiratory therapist, an infection control professional, a research specialist, and a physician adviser. Having the team report directly to the hospital's Infection Control and Adult Critical Care Committees maximized support for recommendations and provided a direct link from patient care to hospital administration. By identifying issues, evaluating patient care processes, performing literature searches, and monitoring compliance, the team implemented numerous interventions, including policy and procedure changes, purchasing of equipment, and implementation of various education tools. RESULTS: Each member of the Critical Care Bug Team contributed to a synergized effort that may have produced the desired outcome of decreasing ventilator-associated pneumonia rates. Except for August 1998, ventilator-associated pneumonia rates have been below the 75th percentile since May 1998. CONCLUSION: This study illustrates the effectiveness of a multidisciplinary team approach devised to reduce and stabilize ventilator-associated pneumonia rates in a medical-surgical intensive care unit.

Adult↗

PubMed2000

Selective referral to high-volume hospitals: estimating potentially avoidable deaths.

CONTEXT: Evidence exists that high-volume hospitals (HVHs) have lower mortality rates than low-volume hospitals (LVHs) for certain conditions. However, few employers, health plans, or government programs have attempted to increase the number of patients referred to HVHs. OBJECTIVES: To determine the difference in hospital mortality between HVHs and LVHs for conditions for which good quality data exist and to estimate how many deaths potentially would be avoided in California by referral to HVHs. DESIGN, SETTING, AND PATIENTS: Literature in MEDLINE, Current Contents, and First-Search Social Abstracts databases from January 1, 1983, to December 31, 1998, was searched using the key words hospital, outcome, mortality, volume, risk, and quality. The highest-quality study assessing the mortality-volume relationship for each given condition was identified and used to calculate odds ratios (ORs) for in-hospital mortality for LVHs vs HVHs. These ORs were then applied to the 1997 California database of hospital discharges maintained by the California Office of Statewide Health Planning and Development to estimate potentially avoidable deaths. MAIN OUTCOME MEASURES: Deaths that potentially could be avoided if patients with conditions for which a mortality-volume relationship had been treated at an HVH vs LVH. RESULTS: The articles identified in the literature search were grouped by condition, and predetermined criteria were applied to choose the best article for each condition. Mortality was significantly lower at HVHs for elective abdominal aortic aneurysm repair, carotid endarterectomy, lower extremity arterial bypass surgery, coronary artery bypass surgery, coronary angioplasty, heart transplantation, pediatric cardiac surgery, pancreatic cancer surgery, esophageal cancer surgery, cerebral aneurysm surgery, and treatment of human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS). A total of 58,306 of 121,609 patients with these conditions were admitted to LVHs in California in 1997. After applying the calculated ORs to these patient populations, we estimated that 602 deaths (95% confidence interval, 304-830) at LVHs could be attributed to their low volume. Additional analyses were performed to take into account emergent admissions and distance traveled, but the impact of loss of continuity of care for some patients and reduction in the availability of specialists for patients remaining at LVHs could not be assessed. CONCLUSIONS: Initiatives to facilitate referral of patients to HVHs have the potential to reduce overall hospital mortality in California for the conditions identified. Additional study is needed to determine the extent to which selective referral is feasible and to examine the potential consequences of such initiatives.

California↗

PubMed2006

Predictors of course satisfaction and perceived course impact of addiction nurses undertaking a postgraduate diploma in addictive behaviour.

The effectiveness and impact of continuing education for specialist nurses working with drug and alcohol had been poorly documented and the purpose of this study was to enhance our understanding of this process. The aims of the study were to identify predictors of course satisfaction and perceived course impact and to examine students' satisfaction with modules' learning outcomes and their applications to practice. This study was a cross-sectional survey of 46 part-time students enrolled a Postgraduate Diploma in Addictive Behaviour. Three instruments were used to measure modules' satisfaction, post-course satisfaction (PCSQ-18) and on-the-job impact (CIQ-17). The findings provided some support on the effect and impact of an educational programme on the practice development of addiction nurses. Within the multilayered hypothesis, the results indicate that expectations on the Health Education and Prevention Module were the only significant predictor of course satisfaction and Expectation of the Special Population Module was the only significant predictor of course impact on professional practice. Clinical placements have had a significant impact on professional practice of addiction nurses. Further evaluative studies need to be undertaken to examine the impact of educational programmes on its applications to clinical practice and the quality of care provided.

Adult↗

PubMedDate not supplied

Managing MICA clients in a modified therapeutic community with enhanced staffing.

To determine how effective a modified therapeutic community (TC) with enhanced mental health staffing would be in treating mentally ill chemical abusing (MICA) clients in a "mainstream" program, Project Return Foundation, Inc. (PRF) conducted a treatment outcome evaluation study involving 438 residents. Client admissions were screened by mental health specialists for Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994) diagnoses and then placed into one of three diagnostic groups: non-MICA; general MICA (not requiring psychotropic medication); and, severe MICA (requiring psychotropic medication). Clients were administered the Tennessee Self-Concept Scale (TSCS; Roid & Fitts, 1991) after admission and at 6-month intervals thereafter. Results indicated that: (a) the three diagnostic groups were significantly different at initial TSCS testing, with the non-MICA group evidencing the least lowest measures of self-esteem and lesser degrees of psychopathology; the severe MICA group had the lowest psychological scores; (b) all three diagnostic groups showed significant improvement in their TSCS scores after 6 to 7 months of treatment; (c) covariance analyses observed that the three diagnostic groups did not significantly differ at 6 month testing when the initial TSCS testing was taken into account; and, (d) significant gender differences on several TSCS scales were noted, in that women scored lower than men in self-esteem and higher than men in psychopathology. Research limitations and clinical observations are considered.

Adult↗

PubMed2003

[Structured treatment and teaching programs and an improvement in private health care lead to a better quality of diabetes care. JEVIN, a population-based trial 1989/90 up to 1999/2000].

UNLABELLED: AIMS AND HYPOTHESES: JEVIN ( Jena's St. Vincent Trial) is a prospective, 10-year follow-up, population-based survey of all insulin-treated patients with type 1 and type 2 diabetes mellitus aged 16-60 years and living in the city of Jena (100,000 inhabitants), Thuringia. It aims to show the effects of recent changes in the health care system and new treatment strategies. During the period from 1989/90 to 1994/95, the health care system was decentralized. There has been an broad implementation of postgraduate educational courses for primary care physicians, of structured treatment and teaching programs (TTP), of intensified insulin therapy, and blood glucose self-monitoring for all patients. PATIENTS AND METHODS: 190 patients (83% of the target population), 244 patients (90%) and 261 patients (90%) were studied in 1989/90, 1994/95 and 1999/2000, respectively. RESULTS: Up to 1994/95, the relative HbA(1c) (HbA(1c)/mean normal) of patients with type 1 diabetes increased (1994/95: 1.65 +/- 0.35 vs. 1989/90: 1.52 +/- 0.31; p = 0.002). For patients with type 2 diabetes mellitus it remained constant (1.75 +/- 0.4 vs. 1.78 +/- 0.31; p = 0.669). During the period from 1994/95 to 1999/2000, there was a substantial improvement in the relative HbA(1c) of both, patients with type 1 (1.48 +/- 0.3; p < 0.0001), and type 2 diabetes (1.47 +/- 0.25; p < 0.0001). Up to 1999/2000, 87.7% of the patients with type 1 (1989/90: 0%, 1994/95: 73.2%) and 96.6% of the patients with type 2 diabetes (1989/90: 0%, 1994/95: 89.7%) participated in TTPs. Similarly, the percentage of patients with intensified insulin therapy (type 1/2: 1989/90: 5.3%/3.4%, 1994/95: 80.3%/30.8%, 1999/2000: 94.7%/48.3%) and the frequency of weekly blood glucose self-monitoring (type 1/2: 1989/90: 1 [0-28]/0 [0-21], 1994/95: 25 [0-49]/14 [0-35], 1999/2000: 28 [0-70]/21 [0-46]) increased. Moreover, there was a drastic improvement in private health care: up to 1999/2000, about 90% of all the patients studied were treated by primary care physicians who took part in postgraduate educational courses. CONCLUSIONS: During the past decade, there has been a substantial improvement in the quality of diabetes control. The broad implementation of structured TTPs, intensified insulin therapy, and blood glucose self-monitoring for patients with type 1 and 2 diabetes mellitus seem to be the major cornerstones for the improved quality of diabetes care. However, the impressive improvement in the quality of diabetes care in patients with type 2 diabetes mellitus seems not to be related mainly to an increase (about 10% vs. 20% in type 1 diabetes) in the number of patients under specialist care, but rather to an improvement in the quality of diabetes therapy administered by private health care physicians.

Administration, Oral↗

PubMedDate not supplied

Managed care and the quality of children's health services.

Managed care has changed the practice of medicine. The choice of health care providers has been narrowed, physicians are being held financially accountable for the number of services they use, and a new emphasis is being placed on the cost and quality of the care provided. The transition to managed care has occurred with little attention to its impact on access to health care services or the quality of services provided. There is an absence of information about how children fare in these new systems. What little is known indicates that children in managed care arrangements are less likely to be able to be seen by pediatric specialists, and that families and providers are less satisfied under managed care. The impact of these changes on children's health status, however, is yet to be determined. For children with special needs, the problems of coordination of care, coverage of needed services, and the choice of the appropriate pediatric subspecialists, many of which existed in traditional fee-for-service systems, persist under managed care. In spite of all of the negative anecdotes about managed health care, managed care's focus on its population of enrollees and its heightened sense of a need for health care accountability bring exciting new opportunities to measure and improve the health care children receive. A new emphasis is being placed on practicing evidence-based medicine; the focus is on closing the gap between what is known (effective, evidence-based care) and what is done (current practice). Improved health outcomes and reduced health care costs have been documented in demonstration projects in neonatal intensive care units and in pediatric offices. Applying the principles of these learning collaboratives and employing the tools of continuous quality improvement in health care are urgent challenges that deserve to be met. Health plans, physicians, health care purchasers, regulators, families, and their children must work together to assure that children receive the highest-quality care possible--care that is technically excellent and medically appropriate, and that improves the health of our children.

Child↗