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PubMed2002

The value of clinical judgement analysis for improving the quality of doctors' prescribing decisions.

BACKGROUND: Many initiatives are taken to improve prescribing decisions. Educational strategies for doctors have been effective in at least 50% of cases. Some reflection on one's own performance seems to be a common feature of the most effective strategies. So far, such reflections have mainly focused on the observed outcomes of the doctors' decisions, i.e. on what doctors do in practice. Studies in other fields have shown that another form of feedback based on the analysis of judgements may be useful as well. OBJECTIVES: The objectives of the study were to discuss the principles underlying clinical judgement analysis, give examples of its use in the medical context, and discuss its potential for improving prescribing decisions. RESULTS: Clinical judgement analysis can look behind the outcome of a decision to the underlying decision process. Carefully constructed or selected case material is required for this analysis. Combining feedback on outcomes with feedback based on clinical judgement analysis offers doctors insight both in what they do, and why or when they do it. It may reveal determinants of decision making which are not available through unaided introspection. Interventions using this combination of feedback for improving doctors' prescribing behaviour have been (partly) successful in 4 cases and unsuccessful in one case. CONCLUSIONS: Clinical judgement analysis gives doctors a structured reflection on the decision-making policy, and can help them to improve their future decisions. It may be especially useful for groups of doctors who try to work towards a consensus policy. The approach is not very helpful when simple decision rules are appropriate.

Clinical Competence↗

PubMed1989

Media power and public mental health policy.

The author describes the functions of the news media and their influence on public mental health policy making. News media functions are divided into the categories of selecting the news, reporting information, serving as a channel of communication, presenting views and opinions, and legitimizing the issues. These functions are illustrated by focusing on a highly publicized New York City policy to involuntarily hospitalize mentally ill homeless people living in the streets. Strategies are suggested to mental health professionals on how to effectively interact with the news media.

Administrative Personnel↗

PubMed1992

A federal/state partnership for health system reform.

In view of the continued lack of consensus regarding health system reform, a new approach is needed to the pluralism that characterizes the U.S. political scene. A two-step strategy can help to break the deadlock around health care financing and provision: a framework around which to shape federal/state responsibility for health care and a process to ensure that policy is translated into action. This strategy, called a federal/state compact for health, builds on actions already under way in several states and represents a process that is both incremental and comprehensive in nature. The federal government would take the lead regarding policy making, financing, and establishing benefits. The states would administer the program with flexibility similar to that existing in Canada's provinces.

Health Policy↗

PubMed1996

The future of health care in six European countries: the views of policy elites.

A recent study was made of the views of politicians, representatives of trade unions, business organizations, and others likely to be influential in policy making, on the future of health care provision in six European Union (E.U.) countries. This article discusses the findings. While common problems of rising cost resulting from population aging are recognized in all countries, the way these issues are interpreted and the policies seen as appropriate to tackle them differ. Views are strongly influenced by the organizational structure of the existing provision. This supports the "new institutionalist" view that policy feedback plays an important role in shaping policy reform. It also indicates that the potential for convergence in E.U. social policy is more limited than suggestions that the single European market will lead to an "ever closer union" might imply.

Attitude to Health↗

PubMed2003

[Israeli guidelines for investigation and management of SARS cases and their contacts].

As the first emerging epidemic of the 21st century, SARS has raised much interest and fear among statesmen, economists, and the general public, as well as within the medical community. This new disease is characterized by several daunting challenges, including person-to-person transmission, an environmentally resistant agent, a non-specific clinical presentation, and a high fatality rate among high risk individuals. In Israel, as elsewhere, public health authorities were forced to quickly design appropriate measures to confront this new threat. The Israeli guidelines for surveillance, epidemiologic investigation and intervention in the event of a SARS outbreak were drafted in the absence of complete data on some of the most basic epidemiologic characteristics of the disease. Discrepancies between published guidelines from several countries made the decision-making process even more complicated. We describe the epidemiologic guidelines for SARS drafted by the Israeli working group, as well as the considerations on which they are based. The recent experience with this new outbreak has already provided several valuable lessons on policy making which may help future planning for emerging and re-emerging infectious diseases.

Disease Outbreaks↗

PubMed1988

Recent trends in financing long-term care.

There has been dramatic change in the financing of long-term care in the last few years. Major private insurance carriers have introduced long-term care insurance policies to meet some of the custodial care needs of a variety of consumer groups, including old and young retirees as well as current employees. Newer policies are tying coverages more closely to a measure of disability that reflect the ability of persons to live independently. Insurers, consumer groups, and policymakers have come to understand the importance of developing innovative financing mechanisms that emphasize prefunding and cash accumulation to make policies more affordable and more desirable to a broader spectrum of the aged and nonaged population.

Industry↗

PubMedDate not supplied

Agenda setting within a community-based food security planning process: the influence of power.

OBJECTIVE: To determine the effectiveness of using citizen politics as a framework for empowering citizens to build a community food security agenda. DESIGN: A critical perspective, case study design, and multiple qualitative methods were used. PARTICIPANTS/SETTING: Forty-four participants were purposefully recruited to participate in a community-based planning process called a search conference (SC). Seven additional disenfranchised stakeholders who did not attend the SC were also recruited to participate. PHENOMENON OF INTEREST: To assess how power influenced agenda setting and to determine the extent to which disenfranchised stakeholders' most salient interests were incorporated into the final SC action agendas. ANALYSIS: The constant comparison method, content analysis, and consensus were used to produce the final analysis. RESULTS: Power influenced agenda setting by managing knowledge, problem framing, trust, and consent. Two of seven of disenfranchised stakeholders' most salient interests, including need for adequate food preparation skills and increased availability of locally produced foods, were incorporated into the final SC action agendas. CONCLUSIONS AND IMPLICATIONS: Citizen politics can be used to build a community food security agenda on issues that are not at odds with stakeholders in positions of power. To bring about change on issues in which power differences between groups are substantial, additional theoretical frameworks and public policy-making models are needed.

Adult↗

PubMed2005

Home health nursing care agenda based on health policy in Korea.

Home health nursing care (HHNC) in Korea has taken on an important role under the mandate of the national health care system since 2000. This program was developed to verify the possibility of early discharge of hospitalized patients and cost containment through a research and development project that was conducted with the government from 1994 to 1999. The process of development of HHNC provided an opportunity to realize the advancement and changes in the system into a consumer-focused structure. This is an important turning point for the Korean health care system that suggests certain possibilities for building a foundation for further changes in the service delivery structure. The structure, which had been limited to a supplier-oriented model, is moving to a consumer-oriented structure. Accordingly, the major function and role of nursing policy makers in Korea is to develop an agenda and alternatives for policy-making in a systematic manner and to present implementation strategies clearly.

Aged↗

PubMed1984

[A change of attitude among health personnel: a function of the schools of public health].

This presentation examines the problem of certain attitudes of persons employed in health and other sectors, and of the beneficiary population itself which, though not blocking, at least make it difficult to promote the attainment of health for all based on primary care. The author describes the changes of attitude and behavior patterns needed both in the whole population, for whose sake the changes are needed, and in those charged with establishing policies and providing health care. At the same time, he identifies the functions that schools of public health may have to perform in order to promote and bring about those changes. With a precise idea of what the desirable changes are and what they consist of, the article examines in detail the principal areas of interest, which it distinguishes as follows: the meaning of health; the meaning of health care and health development; the scope of policy-making; intersectoral and multidisciplinary collaboration; community involvement and self-care; cost-containment of medical care; health system organization and operation; health management training, and health manpower development. The author concludes by underscoring the vital importance of understanding the meaning of health for all and of taking cognizance of the current deficiencies of the health education and service systems, but states that it is just as important to keep an optimistic and positive attitude.

Attitude of Health Personnel↗

PubMed1993

Diffusion of minimally invasive therapy in The Netherlands.

In the context of the European project, the diffusion of 10 selected cases of minimally invasive therapy (MIT) in the Dutch health care system was documented and analyzed. In each case the diffusion pattern resulting from the balance of stimulating and impeding factors is described, and summarized in a matrix framework. Budgetary pressures, lack of evidence on effectiveness and physician conservatism are the most important factors impeding diffusion of MIT. Patient demand, media reporting and presence of medical innovators are important diffusion-stimulating factors. Finally, a judgment is made on the policy implications of these findings, based on a comparison of the extent and speed of the diffusion of each case, the quality of evidence on effectiveness and cost-effectiveness and, in a few cases, existing policies. In most cases, more active policy making, either stimulating or otherwise guiding diffusion, would be desirable.

Angioplasty, Balloon, Coronary↗

PubMed1999

The cost of living: kidney dialysis, rationing and health economics in Britain, 1965-1996.

How important is research in shaping policy when a new life-saving medical technology becomes available, but happens to be very expensive? Taking the case of kidney dialysis, this paper argues that the emerging discipline of health economics had little influence relative to national differences in health service organization and cultures of expectation of provision. Paradoxically, the most effective covert rationing was achieved under the British NHS which ostensibly provides free care for all, while the uncentralised market system in the US gave way, on this issue, to almost universal state-subsidised provision. Under the British system, the most cost-effective options for renal care tended to flourish, but some patients were turned away. Physicians have been held responsible for complying with covert rationing: this paper suggests that early gearing towards socially-useful survival filtered back to selection at primary level, possibly continuing long after specialists wished to expand. Public outcry, though muted, reached parliament and caused minor shifts in policy; the main aim of the voluntary pressure campaign, to release more organs for transplant through 'opt-out', remained unrealised in the UK. Yet dialysis was targetted for expansion in the 1980s just at the point when health economists were presenting evidence for its low cost-effectiveness compared with other expensive interventions. According to the main strand of argument in this paper, comparisons with other countries and between regions were most influential in breaking the hold of covert rationing: policy making by embarrassment. However, in the 1990s, there are both theoretical discussions of explicit rationing, and open intiatives afoot to target dialysis for rationing.

Health Care Rationing↗

PubMed1992

Health care technology transfer in Latin America and the Caribbean.

The greatest problem concerning health care technology for developing countries is that they are dependent upon the industrialized world for technology. The only short-term solution to this problem is to improve the choices that are available to them. This goal will require changes in the structure and processes of policy making. A particular difficulty for these countries is the lack of trained personnel in fields related to technology assessment.

Developing Countries↗

PubMed2001

Using the Internet in the management of asthma.

The ultimate goals of managing asthma are to eliminate death, prevent or promptly treat exacerbations, and maximize the quality of life and health status of patients. Current strategies include appropriate education, trigger control, and timely access to effective pharmacotherapy and follow-up. Internet-based technologies have emerged as potentially powerful tools to enable meaningful communication and proactive partnership in care for various medical conditions. The main types of Internet-based applications for asthma management include remote monitoring and feedback between health professionals and their patients; online education and marketing for either patients or professionals; networking and collaborative research; and administrative oversight through policy making, planning, and decision support. With increased understanding of integrated disease management and the technostructural as well as psychodynamic issues related to Internet use, further refinement and evolution of the Internet and related technologies may drastically improve the way we monitor, educate, treat, and establish policies for this global problem while attending to individual or local community needs. This review presents a conceptual overview of the current challenges and use of the Internet for improving asthma management through timely and tailored education and appropriate access to health care expertise.

Asthma↗

PubMed2004

Ageing and healthcare costs in Australia: a case of policy-based evidence?

There have been dire predictions that population ageing will result in skyrocketing health costs. However, numerous studies have shown that the effect of population ageing on health expenditure is likely to be small and manageable. Pessimism about population ageing is popular in policy debates because it fits with ideological positions that favour growth in the private sector and seek to contain health expenditure in the public sector. It might also distract attention from the need to evaluate the appropriateness and effectiveness of current patterns of care. Pessimistic scenarios have stifled debate and limited the number of policy options considered. Policy making in Australia would be improved if we took a more realistic view of the effect of population ageing on health expenditure.

Australia↗

PubMed1997

Risk ranking by perception.

The study of people's perception and acceptability of risk is important in understanding the public reaction to technology and its environmental and health impact. The perception of risk depends on several factors, including early experiences, education, controllability of the risk, the type of consequence, and the type of person(s) who makes the judgment. This paper reviews some of the main factors influencing people's perception and acceptability of risk. Knowledge about which factors influence the perception of risk may enhance the understanding of different points of view brought into risk controversies, improve risk communication, and facilitate policy making. Results from a risk ranking by perception survey conducted in Ghana are also presented.

Environmental Health↗

PubMed2001

The lives of drug injectors and English social policy.

The lives of drug injectors are characterized by a number of personal, social and economic circumstances, which are linked to the tenets of social policy. Prior to the emergence of HIV and AIDS little research was directed towards understanding the lives and behavior of drug injectors. However, as more was learnt about the virus and the ways in which people behave, drug injectors became an important focus for research and policy making in relation to HIV and AIDS. However, there are wider life issues outside of those of HIV and AIDS that also affect drug injectors. This paper highlights some of these considerations and the value of a holistic approach to understanding drug injectors' lives in social policy; an approach that could usefully be applied to other groups of people.

Education↗

PubMed1995

The epidemiologic transition to chronic diseases in developing countries: cardiovascular mortality, morbidity, and risk factors in Seychelles (Indian Ocean). Investigators of the Seychelles Heart Study.

The occurrence of cardiovascular diseases (CVD) and related risk factors was evaluated in Seychelles, a middle level income country, as accumulating evidence supports increasing rates of CVD in developing countries. CVD mortality was obtained from vital statistics for two periods, 1984-5 and 1991-3. CVD morbidity was estimated by retrospective review of discharge diagnoses for all admissions to medical wards in 1990-1992. Levels of CVD risk factors in the population were assessed in 1989 through a population-based survey. In 1991-93, standardized mortality rates were in males and females respectively, 80.9 and 38.8 for cerebrovascular disease and 92.9 and 47.0 for ischemic heart disease. CVD accounted for 25.2% of all admissions to medical wards. Among the general population aged 35-64, 30% had high blood pressure, 52% of males smoked, and 28% of females were obese. These findings substantiate the current health transition to CVD in Seychelles. More generally, epidemiologic data on CVD mortality, morbidity, and related risk factors, as well as similar indicators for other chronic diseases, should more consistently appear in national and international reports of human development to help emphasize, in the health policy making scene, the current transition to chronic diseases in developing countries and the subsequent need for appropriate control and prevention programs.

Adult↗

PubMed2001

The need for youth-oriented policies and programmes on responsible sexuality in Argentina.

Since the mid-1990s, several provincial bills have been passed in Argentina mandating the creation of programmes for family planning and sexual health services and education. A National Plan for Integrated Health Care for Adolescents was also passed but resources and actual programmes remain limited. The policy process has been fraught with difficulties, owing to a strong alliance between the State and the Catholic church. Provision of contraceptives to adolescents has been one of the most contentious issues, as adolescents are legally minors and need parental permission to use family planning. NGOs are working with young people to help them to voice their perspectives and demands. The Programme for Responsible Sexuality was launched by the Province of Buenos Aires in 1999, in response to concrete demands on the part of poor communities for sexual and reproductive health services, including for young people. This Programme came to an abrupt end with the change of governor in that same year, illustrating the complexity of the policy-making process. These experiences demonstrate the urgency to develop strategies and set up task forces for effective advocacy of health and social programmes, and to make political leaders more aware of the social costs of refusing to support these.

Adolescent↗