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An extremely difficult contract negotiation between a collective bargaining unit and a hospital resulted in a vote to strike by the nursing staff before reaching a final agreement. The authors describe the factors that led up to the strike vote. Realistic yet optimistic strategies for developing a working relationship with the bargaining unit leadership and the nursing staff are described.
BACKGROUND: GPs must make difficult screening and diagnostic decisions regarding genetic testing for different cancers. Educational programs may improve knowledge and enable more appropriate referral. METHODS: A postal survey of all general practitioners (GPs) in Northern Ireland (N = 534; response rate = 49.4%) asked GPs if they would attend 3 different types of training courses in genetics. RESULTS: Almost 75% indicated that they would be likely and/or very likely to attend such courses. Women and GPs who had been qualified recently were most likely to attend (P < .005, P < .05). CONCLUSION: The results suggest that GPs are interested in training courses. Male GPs and GPs who have been qualified for longer should be specifically targeted.
The objective of this communication is to introduce a conceptual framework for a study that applies a rigorous systems approach to rural disaster preparedness and planning. System Dynamics is a well-established computer-based simulation modeling methodology for analyzing complex social systems that are difficult to change and predict. This approach has been applied for decades to a wide variety of issues of healthcare and other types of service capacity and delivery, and more recently, to some issues of disaster planning and mitigation. The study will use the System Dynamics approach to create computer simulation models as "what-if" tools for disaster preparedness planners. We have recently applied the approach to the issue of hospital surge capacity, and have reached some preliminary conclusions--for example, on the question of where in the hospital to place supplementary nursing staff during a severe infectious disease outbreak--some of which we had not expected. Other hospital disaster preparedness issues well suited to System Dynamics analysis include sustaining employee competence and reducing turnover, coordination of medical care and public health resources, and hospital coordination with the wider community to address mass casualties. The approach may also be applied to preparedness issues for agencies other than hospitals, and could help to improve the interactions among all agencies represented in a community's local emergency planning committee. The simulation models will support an evidence-based approach to rural disaster planning, helping to tie empirical data to decision-making. Disaster planners will be able to simulate a wide variety of scenarios, learn responses to each and develop principles or best practices that apply to a broad spectrum of disaster scenarios. These skills and insights would improve public health practice and be of particular use in the promotion of injury and disease prevention programs and practices.
Using placebos in day-to-day practice is an ethical problem. This paper summarises the available epidemiological evidence to support this difficult decision. Based on these data we propose to differentiate between placebo and "knowledge framing". While the use of placebo should be confined to experimental settings in clinical trials, knowledge framing--which is only conceptually different from placebo--is a desired, expected and necessary component of any doctor-patient encounter. Examples from daily practice demonstrate both, the need to investigate the effects of knowledge framing and its impact on ethical, medical, economical and legal decisions.
BACKGROUND: In 1988, two practices attempted to improve the prescribing of antibiotics for sore throat. The initiative produced only modest improvements in prescribing practice, a finding the authors found difficult to explain. This paper reanalyses the data from an audit of antibiotic prescribing for sore throat in general practice. OBJECTIVE: Our aim was to demonstrate the use of Shewhart control charts and to obtain fresh insight into the variations in clinical practice revealed in clinical audit data. METHODS: We use Shewhart control charts to explore variation in antibiotic prescribing between GPs and to suggest the action most likely to result in improvement. RESULTS: Using control charts, it is possible to distinguish two categories of GPs: low prescribers of antibiotics and high prescribers of antibiotics. Low prescribers of antibiotics show common cause variation, indicating that their prescribing is a stable process. Among low prescribers, improvement can best be achieved by changing the common underlying process. One high prescriber of antibiotics is affected by special cause variation. Among high prescribers, improvement can best be achieved by investigating the special causes affecting this GP and learning lessons from the findings. CONCLUSION: The original improvement effort took the same action on all GPs in both practices. Our analysis suggests that such an approach was unlikely to be successful and that different actions were needed for high and low prescribers. The control charts provide fresh insights on the original data and guide improvement efforts.
A purposive and convenience sample of 16 women and four men receiving informal and formal care for their activities of daily living either at home or institutions in Southeast Washington, USA was interviewed. Qualitative findings related to asking for help, getting and receiving help, interpersonal aspects of receiving help, and met and unmet needs are reported. Some seniors found it more difficult to ask for and accept help and there were gender differences, with men tending to adopt a more logical and pragmatic approach while women viewed receiving help as a loss of independence and an invasion of privacy. Intimacy and nudity were also threats for women. Three styles of adjustment and acceptance were identified within the data and related to positive acceptance, resigned acceptance and passive acceptance. There appeared to be a relationship between independence and control, with elders losing some independence but retaining control through choice, payment and involvement in decision making. Reciprocity was found to bring added value to relationships between care providers and elders, with a rhythm and symmetry developing in relationships where needs were known, anticipated and met. Seniors should be encouraged to plan for their future and to find out about local help and services available to them in advance of their requiring any assistance.
OBJECTIVE: To design and implement a reporting system for quality of long-term care to empower consumers and to create incentives for quality improvement. To identify a model to approach this technically and politically difficult task. APPROACH: Establishment of a credible and transparent decision process using a public forum. Development of the system based on: (1) review of the literature and existing systems, and discussions with stakeholders about strengths and weaknesses; (2) focus on consumer preferences in the design; and (3) responsiveness to industry concerns in the implementation. LESSONS LEARNED: None of the existing systems appeared to be a suitable model. We decided to develop an entirely new system based on three key design principles that allowed us to tailor the system to consumer needs: (1) designing a decision tool rather than a database; (2) summarizing rather than simplifying information; and (3) accounting for the target audience in the creative execution. Industry concerns focused on the burden of the system, the potential for errors, and the possible communication of a negative impression of the industry. As methodological and data limitations prevented us from resolving those concerns, we addressed them by using cautionary language in the presentation and by making a commitment to incorporate improvements in the future. All stakeholders regarded the final design as an acceptable compromise. CONCLUSIONS: Despite its potentially controversial nature and many methodological challenges, the system has been well received by both the public and the industry. We attribute this success to two key factors: a collaborative decision process, in which all critical design and execution choices were laid out explicitly and debated with stakeholders in a public forum, and realism and honesty regarding the limitations of the system.
AIMS AND OBJECTIVES: To study the perspectives of nurses on (i) the process of decision-making regarding the placement of feeding gastrostomies, (ii) their role in the process, (iii) the impact this participation has on them personally and (iv) gastrostomy placement in general. BACKGROUND: The decision to commit patients to long-term feeding using a gastrostomy tube can be very difficult, particularly when the anticipated benefits are uncertain. Strategies to improve such decision-making are required. Nurses are in an excellent position to provide valuable insights regarding this decision-making and their increased participation in this process might substantially improve it. DESIGN: A cross-sectional, exploratory design using in-depth semi-structured interviews and a self-administered questionnaire. METHODS: In-depth semi-structured interviews with 17 nurses experienced in percutaneous endoscopic gastrostomy decision-making were undertaken and analysed. RESULTS: Individuals making decisions regarding feeding gastrostomy placement were observed to be insufficiently informed regarding the device and the ramifications of its placement. Nurses were perceived to play an important, although underused, role in decisions to commit patients to long-term feeding. Participation in the making of these decisions may be stressful to nurses, particularly when the only result anticipated is the sustaining of a life of poor quality. Sixteen nurses reported that they would not want to have a gastrostomy for themselves if they were unable to maintain some quality of life. Strategies that could improve decision-making were suggested. CONCLUSIONS: Decision-making could be improved by providing better information to decision makers. A team-orientated approach and more active dialogue with regard to care planning among health professionals, especially between doctors and nurses is needed. Effective decisions regarding feeding gastrostomy placement require adequate resources, especially sufficient time for caregivers to communicate effectively with those who must make these decisions. RELEVANCE TO CLINICAL PRACTICE: The role of nurses in decision-making regarding commitments to long-term feeding using gastrostomy tubes could be effectively augmented.
Addressing racial differences in US health care is difficult, in part because the origins of these differences are complex and poorly understood and also because only some differences may represent legitimate agendas for reform. For example, racial differences that result from differences in access or from clinician prejudices are symptoms of a problem that must be addressed; in contrast, racial differences that arise from different preferences for health care might be seen as acceptable consequences of variation in personal or cultural values that are worth respecting and preserving. However, we believe that this distinction is sometimes overstated. We present several fictitious clinical stories to illustrate how what appear to be individual or cultural preferences are often substantially shaped by modifiable practices of the health care system. True differences in preference that are worthy of respect surely exist between individuals or demographic groups, but some apparent differences in preference may actually reflect problems with the health care system that are worthy of remediation. Uncovering the hidden constraints that we impose on health care choice may help us reduce unwanted disparities in health care.
Difficult dilemmas arise when resources become scarce in intensive care units (ICUs). When there are fewer beds available than patients who need them, how are those beds to be distributed? In this report, I discuss such rationing dilemmas from the context of John Rawls' theory of justice. Principles of justice can be chosen by clinicians and used to set priorities in the distribution of scarce ICU beds. These principles consist of a ranking of patients based on available prognostic data. Such a ranking would be the most fair way of distributing scarce ICU beds within a Rawlsian conception of justice. It is a ranking that would be chosen by the patients themselves, were they able to consider the matter from a rational and impartial perspective.
Given the wide range of available health care personnel handwashing agents, selection of an appropriate product may be difficult. This decision may be made on the basis of user preference, cost, or other factors unrelated to product effectiveness. Four criteria--efficacy, safety, cost, and acceptability--are appropriate for systematic evaluation of handwashing products. These criteria are applied to para-chloro-meta-xylenol (PCMX), a compound used with increasing frequency in health care personnel handwashing agents. Published data regarding the biochemical properties, efficacy, and safety of PCMX are summarized. We conclude that the substance appears to be safe and efficacious. However, the activity of PCMX is highly formula-dependent and many of the studies available in scientific literature have been conducted in Europe using a variety of testing conditions and formulations different from those currently available in the US. Clinical studies of marketed formulations are beginning to appear in the literature. Such studies will provide the data needed for adequate product evaluation.
Surgical techniques always imply uncertainty about risks and outcome. Many law systems explicitly recognise the patient's right with respect to informed decision-making. This right refers to information about the risks and benefits, the experience of the surgeon, and the performance of the surgical team. In practice, the informed consent is difficult to obtain, and patients have often difficulty to recall the adequate information. Especially when risk and benefit assessment has to be done with the focus on a new technology that is expected to prevent disease in the future, safety of this less invasive technique compared with the current strategy is important. Therefore, it is also of importance to look at the mid-term and long-term follow-up. Appropriate knowledge of the technology involved, follow-up data, and risk information provided by a professional safety-committee should be the input of the informed consent procedure.
BACKGROUND: A consensus conference was convened to define the current state and important gaps in knowledge and needed research on "Palliative and Supportive Care in Advanced Heart Failure." EVIDENCE: Evidence was drawn from expert opinion and from extensive review of the medical literature, evidence-based guidelines, and reviews. CONCLUSIONS: The conference identified gaps in current knowledge, practice, and research relating to prognostication, symptom management, and supportive care for advanced heart failure (HF). Specific conclusions include: (1) although supportive care should be integrated throughout treatment of patients with advanced HF, data are needed to understand how to best decrease physical and psychosocial burdens of advanced HF and to meet patient and family needs; (2) prognostication in advanced HF is difficult and data are needed to understand which patients will benefit from which interventions and how best to counsel patients with advanced HF; (3) research is needed to identify which interventions improve quality of life and best achieve the outcomes desired by patients and family members; (4) care should be coordinated between sites of care, and barriers to evidence-based practice must be addressed programmatically; and (5) more research is needed to identify the content and technique of communicating prognosis and treatment options with patients with advanced HF; physicians caring for patients with advanced HF must develop skills to better integrate the patient's preferences into the goals of care.
Medical technology assessment in Italy is considered to have had scant impact on policy. Government has played a limited role in financing evaluative research and increased public funding might therefore be expected to have a positive effect on the contribution that this activity makes to policy. The choice of arrangements for such funding, however, must take account of the broader institutional context in which these operate. Intergovernmental relations in any country are inherently difficult due to the fact that the distribution of powers is in general poorly specified and to a tendency for central government to try to impose itself. Budgetary difficulties may exacerbate the problem. Italy has quite a decentralised system of government and there has been significant disagreement over how to interpret the intergovernmental distribution of powers, including those relating to health care. Central government has also had difficulty in that sector making lower governments accountable for how they spend their central grants and for budget deficits. This has created serious problems for the implementation of medical technology policy developed at the centre. This state of affairs counsels against adopting funding arrangements for evaluative research in which central government plays a dominant role. Probably the most appropriate solution is that of a partnership between the centre and the Regions with each party having an equal say on the medical technologies studied, the evaluative methodologies adopted and how the data produced are used in policy development.(ABSTRACT TRUNCATED AT 250 WORDS)
BACKGROUND: The rapid evolution of outcomes research during the last decade has led to increasing emphasis on measures of health-related quality of life (HRQOL). However, the relatively recent advent of these measures makes it difficult to decide how much weight to attribute to them in decisions about the value of drug therapy. OBJECTIVE: The aim of this article is to discuss the factors that affect the relative importance of HRQOL data in determining the value of drug therapy. CONCLUSIONS: The relative importance of HRQOL data depends on the type of condition and the type of treatment. In chronic conditions, HRQOL may be considered a primary measure of efficacy. In acute conditions, HRQOL is not likely to be a primary efficacy measure, although excluding HRQOL measures may lead to an underestimation of treatment effects. Measures of HRQOL are also likely to be important in the assessment of palliative treatments and, to some extent, preventive treatments (primarily in the measurement of adverse effects). HRQOL measures will be less important in the assessment of curative treatments because these types of treatment are most relevant in acute conditions.
Health care delivery in America is not efficient. Hospitals are not efficient and many are still wasteful. Some of the most blatant wastes in hospitals are staffing patterns that developed during the years of cost reports. Spending patterns become the norm, rather than excess, when they continue unabated for years. There are many reasons for cost increases in health care and specifically in hospitals. However, it is difficult to make these reasons add up to the total cost increase. No one has the answers; observation can only be made of what has been occurring and what continues to occur. Whatever the reason for the increase in health care costs, the consumer will bear the burden because of the circular flow of income and expenditures between the business sector and the household sector. Increased health care costs are passed on to the consumer in the form of increased expenditures for household goods and services or taxes. Ford Motor Company President Mr. Peterson says that $1,500 of every new automobile represents employee health care costs. The American consumer created the demand for health care services, and only the consumer can control the demand. One solution would be to let the consumer bear health care costs directly and remove the inefficiencies created by third party insurance carriers. This hypothesizes that the health care consumer is the most efficient shopper for health care services, and that third party insurance carriers are an important source of inefficiency in the health care delivery system. Many other solutions have been proposed by the government and by the insurance and health care industries, but most have only increased the cost of health care. Perhaps some day the health care industry will learn how to control the dynamics of this four-party purchasing decision. Until then, costs will continue to grow dramatically, and the executives of the industries who compete in the two-party purchasing system will wonder why the process is so complicated.
Often it is very difficult to make decisions involving the termination of aggressive cancer care in the case of patients who are no longer benefiting. Among these patients, our ability to "do everything possible" to continue life is in conflict with "doing the right thing"; the greatest benefit to these patients derives from delivering excellent supportive care and assisting them in understanding and accepting end-of-life issues. Furthermore, in a cost-conscious environment with limited resources, all patients and, indeed, all of society, benefit when aggressive and often costly cancer care is limited to those patients who are likely to benefit. However, these issues are complex, blending treatment science and ethics, and thus, the physician frequently has no objective reference point on which to base the decisions. This paper integrates the principles of ethics (respect for autonomy, beneficence, nonmaleficence, and justice) and three difficult issues encountered by physicians in clinical decision-making in terminal cancer patients in the American healthcare system. These issues include: medical futility and appropriate care, applications of outcomes research in clinical decision-making, and impact of cost, particularly in a managed care environment, on treatment choice. These topics are illustrated with reference to patients presenting to our emergency center with stage IV lung cancer and dyspnea, and the application of an outcomes model under development to predict imminent death in these patients is discussed. Outcomes models may provide patients, their families, and their physicians with objective data on which to base end-of-life decision-making. Minimizing aggressive treatment of terminally ill patients may provide better life quality and will reduce costs during the patients' end of life. Ethics plays a crucial role in integrating medical science, patient choice, and cost in making appropriate decisions.
A common financial model used in business decisions is the cost/benefit comparison. The costs of a proposed project are compared with the benefits, and if the benefits outweigh the costs, the project is accepted; if the costs exceed the benefits, the project is rejected. This model is applicable when tangible costs and benefits can be reasonably measured in monetary units. However, it is difficult to consider intangible factors in this model because intangible factors cannot be readily quantified in money. While some might argue that the financial model should not apply to healthcare decisions, the fact is that costs do enter into the picture. People may decide to forego needed healthcare because they cannot afford it. Healthcare providers may make choices based in part on the costs of diagnosis and treatment, rather than solely on medical information and what is best for the patient. Should financial issues enter into healthcare decisions--decisions about human health and well being? If so, how should the costs and benefits be measured and evaluated? What are some ethical issues and dilemmas involved in such decisions. This paper addresses ethical dilemmas and financial issues in healthcare. A healthcare decision model, which considers medical information, financial information, as well as ethical and other intangible factors, is proposed.