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PubMed2005

The integration of medical specialists in hospitals. Dutch hospitals and medical specialists on the road to joint regulation.

Medical specialists have--notwithstanding governmental policy--acquired a firmly established position in policy-making in Dutch hospitals. In all general hospitals the Executive Board and the Staff Executive frequently and systematically negotiate their interests. Three conclusions may be drawn on the basis of the research reported on in this article. In the first place, it is the primary objective of the medical staff executive to protect the interests of the medical domain against managerial dominance. In the second place, developments suggest that the parties are slowly but surely switching to the joint regulation of overlapping interests. Finally, the trend towards joint regulation is an enormous challenge for medical staff governance.

Hospital Administration↗

PubMed1995

Changing approaches to assessment of environmental inhalation risk: a case study.

Approaches to assessing environmental inhalation risk from asbestos have undergone profound change. In addition to social and political changes, a number of factors have come into play: 1. new technologies 2. new measuring instruments 3. new biological data 4. increased utilization of asbestos 5. regulatory imperatives 6. a redefinition of health risks associated with asbestos. This has occurred over a period of little more than 60 years. Early air-sampling instruments were developed to measure particles and fibers in air. Because asbestosis was a fibrotic disease, all measurements quantitated fibrotic disease risk in the environment by focusing on fibers and particles. Subsequently, the understanding that asbestos forms only fibers in air refocused measurement on fibers, not fibers and particles. As research clarified which fibers reached the lungs, new ways to sample and evaluate air were required. At the same time, changes in understanding of the disease process created the need for a better way to measure risk. In the 1960s, acceptance of the knowledge that asbestos causes both cancer (based on the no threshold assumption for carcinogens) and fibrosis raised the question of which fiber sizes should be measured and what the standard should be. The scientific assumption, prevailing both in 1985-86 and today, of a linear nonthreshold dose-response curve for carcinogens was applied to estimates of risk for asbestos exposure in the workplace, which led OSHA to lower the U.S. standard. In summary, we have attempted to illustrate the close link between state-of-the-art scientific and technical knowledge and policy decisions to control a toxic substance in industrial society. In the best of all possible worlds the science should permit valid estimates of risk and construct measurement techniques that lead to the desired control. If awareness comes early, then the process of policy making should be an iterative one, with incrementally more restrictive control as knowledge of the toxicant improves. The imperative for control of asbestos, as with many other toxic materials, was regulation, not science. That, however, is another story. Regulation of the workplace environment activated use of the science that permits valid estimates of risk and the techniques for measurement and control. The evolving science became part of the debates on control and constantly refocused them. Setting acceptable workplace exposure levels to control inhalation risk from asbestos did not occur on a wide scale until after 1970.(ABSTRACT TRUNCATED AT 400 WORDS)

Air Pollutants, Occupational↗

PubMed2000

Extracorporeal shock wave therapy in orthopedics. Assessment of an emerging health technology.

OBJECTIVE: Extracorporeal shock wave therapy (ESWT) as an emerging technology in orthopedics has been assessed in Austria with the objective to establish a scientific basis for pending and pressing health policy decisions. Despite encouraging results within some indications and the promising prospect of a noninvasive treatment for some orthopedic diseases, it seemed crucial to assess this new field of application in the light of evidence-based standards, without forgetting the reality of healthcare decisions. This article presents the results of the above mentioned assessment in the context of the policy-making process in Germany, Austria, and Switzerland. METHODS: The study is based on an overview of the already existing reviews on the effectiveness of ESWT as carried out by different actors (health insurances and orthopedists), and on an overview of additional literature covering all relevant aspects (mode of action, recommendations, economic estimates). Orthopedic societies, several institutions involved in health technology assessment, and health insurance agencies were contacted in search of further relevant literature, ongoing studies, and assessments. RESULTS: Until now, clear evidence has not been available on the effectiveness of ESWT in four currently recommended indications (tendinosis calcarea of the shoulder, epicondylopathia humeri radialis, calcaneal spur, and pseudarthrosis), although a substantial body of literature has been produced. Despite encouraging results in some indications, the lack of coherent therapy schemes and the poor quality in the design of clinical studies has been serious enough to hinder the drawing of reasonable conclusions. CONCLUSIONS: Due to the rapid diffusion of ESWT and the pressure on reimbursement agencies to prove the ineffectiveness of ESWT, the policy option of a pragmatic approach is recommended to control the diffusion of an uncertain health technology, alongside active research that would allow a more comprehensive appraisal of this potentially interesting treatment strategy in orthopedics.

Austria↗

PubMed2002

Willingness to pay for treated mosquito nets in Surat, India: the design and descriptive analysis of a household survey.

For willingness to pay (WTP) studies to have an appropriate impact on policy making, it is essential that the design and analysis are undertaken carefully. This paper aims to describe and justify the design of the survey tool used to assess hypothetical WTP for treated mosquito nets (TMN) in rural Surat, India and report its findings. Results from qualitative work were used as an input for developing the WTP questionnaire. A total of 1200 households belonging to 80 villages in rural Surat were selected for the study. A bidding format was used to elicit WTP values, using three different starting bids. The scenario was constructed in a way to reduce the possibility of respondents acting strategically. The response rate was 100%. About 79% of the respondents were willing to buy TMNs and the mean WTP was Rs57. Descriptive results of economic and other taste and preference variables are also presented, which include preventive measures used by households and treatment seeking behaviour for malaria. It is observed that WTP as well as demographic variables and prevention methods differ significantly across arms of the trial. This paper suggests that policy-makers could use the evidence following further analysis, along with information on costs of implementation, to ascertain the levels of subsidy that may be needed at different levels of coverage.

Adult↗

PubMed2001

Privacy and confidentiality of genetic information: what rules for the new science?

This review covers the ethical, legal, and policy issues associated with the generation and dissemination of genetic information. First, conceptual issues, such as the definition of terms and the description of two modes of analysis, are addressed. Research findings on public attitudes toward privacy and genetics and other factors relevant to policy making are also reviewed. Second, the example of genetic research is used to highlight the importance of attention to the intrinsic harms associated with violations of genetic privacy. Subtopics include national databases and biobanks, gene brokers, and pharmacogenomics. Third, the example of insurer access to genetic information is used to highlight the importance of attention to discrimination and other instrumental harms associated with failures of regulation. Fourth, a summary of the preceding sections leads into an outline of a program for realizing the benefits of the new science in a manner that affirms rather than erodes privacy and other important values.

Confidentiality↗

PubMed1994

[Incidence and prevalence of genetically-determined disorders in The Netherlands; a literature study].

OBJECTIVE: To analyse if data now available on frequencies of genetic disorders are sufficient to be used in future as indicators when an evaluation of new developments is desired for policy-making purposes. DESIGN: Literature study. SETTING: The Netherlands. METHOD: Using automated literature search systems, papers published before October 1991 were surveyed and an inventory of incidence and prevalence of genetic disorders in the Netherlands was made. RESULTS: Depending on the pattern of heredity differences in available data and their validity were found. Valid data on most of the II congenital anomalies investigated were available from the EUROCAT registration in the northern Netherlands. This method of data collecting is also suitable for the evaluation of prevalence development. On the 29 multifactorial diseases occurring later in life that were investigated many data were available, although the varying sources made comparison difficult. These data were often out of date and had a highly varying validity. Of 3 chromosomal abnormalities the prevalence at birth was known. Of only 22 out of 650 monogenic disorders, described in the Netherlands up to 1991, the prevalence at birth and(or) in the population was known. CONCLUSION: Data on frequency of genetic disorders can be collected but the information now available is insufficient to serve as an indicator for government policy. Frequencies should also be considered in relation to the impact of the disease on the individual, his environment and society.

Adolescent↗

PubMed1989

Concepts in health promotion: the notion of relativism.

'Health promotion' is a new and powerful concept. By some professionals in the field as well as by actors in the policy making spheres, though, the notion may be received with considerable scepticism. We have attributed this scepticism, as well as barriers to include notions of health promotion in day-to-day work, to a lack of knowledge of essential concepts in the health promotion context. In this article we first explore the quintessential nature of 'health' (a capacity of people, rather than an end product of medical care) before we set out to analyze some crucial components of health promotion: integral-ness, intersectorality, holism, and ecology. Integral intervention mixes appear to have synergetic, and therefore cost-effective, results. An intersectoral approach will be necessary to address all determinants of health in an adequate way. Alas, neither integral, nor intersectoral health programs have been documented in depth. The notions of holism and ecology seem to suffer from obscurantism and esoteric elitism, though commendable in their scope. Here, we introduce 'relativism' to combine various valuable approaches into one more comprehensive scheme. Moreover, a 'relativist' approach to health promotion might induce better and more fruitful cooperation among professions. Finally, some research gaps have been identified. Policy development studies remain to have top priority in development of health promotion. Better documentation of efforts in this field will be of crucial importance. Further development of, and research on how to apply relativist approaches may be recommended. Cooperation, and opening up a dialogue between different professions and actors is of great importance in this field.

Ecology↗

PubMed2002

[Valuation of forest damage cost from SO2 emission: a case study in Hunan Province].

Large amount SO2 emission caused serious damage of forest ecosystem in China and calculation of the damage cost is an important issue for policy-making. However, no applicable method was developed to estimate forest damage under different SO2 emission scenarios. Basing on previous field researches on sulfur-related forest impact in China and recent critical load mapping research, this paper presented a model for forest damage calculation by developing a dose-response function that related the damage to cumulative sulfur critical loads. This model was applied to the forests in Hunan, a province in acid rain control zone in China. Results showed that in the business-as-usual case, SO2 emission in Hunan will increase by 120% from 1995 (8.82 mil. ton) to 2020 (19.56 mil. ton), but damage cost will increase by 4.3 times, reaching 6.19 billion RMB in 2020. Results also showed the measures for SO2 control were cost-effective because the marginal damage cost will be about 6000 RMB per ton SO2 in 2020 in BAU case. At current SO2 emission level, marginal benefit will be about 1500 RMB per ton. Uncertainty analysis demonstrated that this model provides reasonable damage estimates and would therefore be applicable in a broad range of policy settings.

China↗

PubMed2000

Stopping poliovirus vaccination after eradication: issues and challenges.

Since 1988 reported polio cases worldwide have declined by about 85% and the number of known or suspected polioendemic countries has decreased from over 120 to less than 50. With eradication of poliomyelitis approaching, issues potentially affecting when and how vaccination against poliovirus can be stopped become extremely important. Because of the potential risks and benefits inherent in such a decision, the best available science, a risk-benefit analysis, contingency plans, a stock pile of poliovirus vaccines, and the endorsement by the global policy-making committees will all be needed before vaccination can be discontinued. The scientific basis for stopping polio immunization has been reviewed by WHO. This Round Table article summarizes the current state of knowledge, provides an update on the processes and timelines for certification, containment, and stopping vaccination, and highlights some of the unanswered scientific questions that will be addressed by further research. These include whether transmission of vaccine-derived poliovirus strains could be sustained so that poliomyelitis could re-emerge in a future unvaccinated population and whether prolonged excretion of vaccine-derived poliovirus from individuals with immune deficiencies could be a mechanism through which this could occur.

Biological Warfare↗

PubMed1999

Conditional uncertainty analysis and implications for decision making: the case of WIPP.

Uncertainty analyses and the reporting of their results can be misinterpreted when these analyses are conditional on a set of assumptions generally intended to bring some conservatism in the decisions. In this paper, two cases of conditional uncertainty analysis are examined. The first case includes studies that result, for instance, in a family of risk curves representing percentiles of the probability distribution of the future frequency of exceeding specified consequence levels conditional on a set of hypotheses. The second case involves analyses that result in an interval of outcomes estimated on the basis of conservative assumptions. Both types of results are difficult to use because they are sometimes misinterpreted as if they represented the output of a full uncertainty analysis. In the first case, the percentiles shown on each risk curve may be taken at face value when in reality (in marginal terms) they are lower if the chosen hypotheses are conservative. In the second case, the fact that some segments of the resulting interval are highly unlikely--or that some more benign segments outside the range of results are quite possible--does not appear. Also, these results are difficult to compare to those of analyses of other risks, possibly competing for the same risk management resources, and the decision criteria have to be adapted to the conservatism of the hypotheses. In this paper, the focus is on the first type (conditional risk curves) more than on the second and the discussion is illustrated by the case of the performance assessment of the Waste Isolation Pilot Plant in New Mexico. For policy-making purposes, however, the problems of interpretation, comparison, and use of the results are similar.

Confidence Intervals↗

PubMed2001

Urban cause-specific socioeconomic mortality differences. Which causes of death contribute most?

BACKGROUND: Cause-specific information on socioeconomic differences in health is necessary for a rational public health policy. At the local level, the Municipal Health Service studies these differences in order to support the authorities in policy making. METHODS: Mortality data of the under 65 age group in The Hague were analysed (1982-1991) at residential area level. RESULTS: Causes of death with a high socioeconomic gradient among males were: homicide, chronic liver disease, 'other' external causes of injury, diabetes, bronchitis, emphysema and asthma, and motor vehicle accidents; and among females: diabetes, ischaemic heart disease, 'other' diseases of the circulatory system, signs, symptoms and ill-defined conditions, malignant neoplasm of cervix, and 'other' diseases. Main contributors to the mortality differences between the highest and lowest socioeconomic quartiles among males were: ischaemic heart disease (17.3%), 'other' diseases of the circulatory system (10.2%), signs, symptoms and ill-defined conditions (9.0%), 'other' external causes of injury (8.6%), and chronic liver disease (7.2%); and among females: ischaemic heart disease (25.5%), 'other' diseases (20.1%), signs, symptoms and ill-defined conditions (18.6%), 'other' diseases of the circulatory system (11.0%), and diabetes (9.1%). Among females the contributions of malignant neoplasms of breast (-16.3%) and colon (-5.5%) and suicide (-4.3%) were negative. CONCLUSIONS: The diseases that are the main contributors to urban socioeconomic mortality differences can be influenced by public health policy.

Adolescent↗

PubMed2004

Human genetic databases and liberty.

This paper examines an act of the Icelandic Parliament on health-sector databases. Both the legislation itself and the manner in which it was presented by the Government to the Parliament and the general public raise various questions about democratic parliamentary procedures, community consultation, autonomy, privacy, professional confidence, control of health data in hospitals and business relationships between medical doctors and biotechnology corporations. A major question to be asked is: In whose interest is it that such sensitive data are handed over to for-profit corporations? Furthermore, is it within the authority of the legislature to authorize politically appointed boards of health institutes to transfer such data without the direct informed consent of the patient and without the relevant physicians' having a say? Does experience teach us to entrust private companies with sensitive personal data? Should the Government be involved in the research policy-making of the biotechnology companies that have been given access to the genetic data of a population, or should the profit motive be the sole deciding influence? That is, should the interest of the shareholders of the companies prevail over the interest of underprivileged groups who are most in need of new methods or medicine to alleviate their situation due to incurable diseases? Or is the invisible hand of the market the only competent decision-maker? Finally, will the proliferation of databases containing sensitive personal data, such as human genetic data, limit our personal liberty?

Biological Specimen Banks↗

PubMed2002

Perceived quality of care of primary health care services in Burkina Faso.

INTRODUCTION: Patients' views are being given more and more importance in policy-making. Understanding populations' perceptions of quality of care is critical to developing measures to increase the utilization of primary health care services. OBJECTIVE: Documentation of user's opinion on the quality of care of primary health care services. METHODS: A 20-item scale, including four sub-scales related to health personnel practices and conduct, adequacy of resources and services, health care delivery, and financial and physical accessibility, was administered to 1081 users of 11 health care centres in the health district of Nouna, in rural Burkina Faso. RESULTS: The respondents were relatively positive on items related to health personnel practices and conduct and to health care delivery, but less so on items related to adequacy of resources and services and to financial and physical accessibility. In particular, the availability of drugs for all diseases on the spot, the adequacy of rooms and equipment in the facilities, the costs of care and the access to credit were valued poorly. Overall, the urban hospital was rated poorer than the average rural health care centre. Analysis of variance showed that, overall, health system characteristics explain 29% of all variation of the responses. CONCLUSION: Improving drug availability and financial accessibility to health services have been identified as the two main priorities for health policy action. Policy-makers should respect these patient preferences to deliver effective improvement of the quality of care as a potential means to increase utilization of health care.

Burkina Faso↗

PubMed2005

Evidence-based medicine in surgical decision making.

There are now five classic steps for analysis of diagnostic and therapeutic medical decision-making policies: (1) formulate a clear clinical question based on a particular patient's problem; (2) search the literature for relevant clinical articles; (3) evaluate the evidence for its validity and usefulness; (4) implement useful findings into clinical practice; (5) audit the validity of the process. The clinician must have the necessary skills to appraise critically the information retrieved. Rather than focusing on the discussion and conclusion sections of articles, the reader should concentrate on the review of the methods and results sections to formulate an opinion regarding the strength of evidence presented in the paper. The process is intellectually demanding and difficult to achieve. This particular step in the validation of evidence implies that each clinician must be methodologically and statistically sound, an "expert," capable of analyzing the method used in that particular publication to achieve the published result.

Decision Making↗

PubMed1990

Public policy--power--professionalism.

This paper is based on two academic papers written for a Bachelor of Nursing program. The first part of the paper consists of an analysis of public policy in the area of Maternity Services in Australia, and more particularly, in Victoria. The analysis follows the work of Richard Simeon, a Canadian public policy analyst, who has drawn strands of both economic and social analysis together. His work asserts that socio economic factors lead to an environment in which power is held by particular groups in society. These powerful groups then have a greater input into the development of values and ideology for that society, that then effect institutions involved in the policy making process. Analysis shows that the re-emergence of Midwifery and the imminent changes in Maternity Services have occurred due to the increasing power of women in society at a time when economic constraints have forced governments to look at ways of rationalising health care. The second part of the paper identifies the traditional characteristics of profession and critically appraises these from a feminist perspective. Discussion includes the concepts of medical dominance, power, the power of caring and existential advocacy. An argument is presented that profession as traditionally portrayed is not necessary for midwives, will not solve the problem of medical dominance, will alienate consumers and will ultimately lead to disunity. Such disunity would cause fragmentation of the powerbase that has led to changes thus far.

Australia↗

PubMed1994

Monitoring international migration flows in Europe. Towards a statistical data base combining data from different sources.

"The paper reviews techniques developed in demography, geography and statistics that are useful for bridging the gap between available data on international migration flows and the information required for policy making and research. The basic idea of the paper is as follows: to establish a coherent and consistent data base that contains sufficiently detailed, up-to-date and accurate information, data from several sources should be combined.... The issues may be tackled more easily if the statistics that are being compiled are viewed as different outcomes or manifestations of underlying stochastic processes governing migration. The link between the processes and their outcomes is described by models, the parameters of which must be estimated from the available data.... The paper discusses the experience of the U.S. Bureau of the Census in combining migration data from several sources. It also summarizes the many efforts in Europe to establish a coherent and consistent data base on international migration." (SUMMARY IN FRE)

Americas↗

PubMed2003

Unique roles of a data and safety monitoring board in vaccine safety trials with compressed timelines and urgent implications.

Studies with urgent implications for public policy and programs represent a special case for monitoring boards, whose responsibilities must include ensuring applicability to policy making and timely communication of results as well as data and safety monitoring. We recently conducted two preseason evaluations of an influenza vaccine, results of which would influence the supply of vaccine for the Canadian annual program. Only 12 weeks were available for planning the studies and 6 weeks for fieldwork and data analysis. The enlisted board played key roles in determining appropriate study design, setting and enforcing rules for study initiation and early termination, monitoring safety, and encouraging timely dissemination of results. An extended role in data monitoring would have been desirable. Providing a safety valve for inevitable tensions between investigators and sponsor was an understated but significant role. Lessons from our experience will be particularly pertinent to future studies of pandemic influenza vaccines.

Canada↗

PubMed2002

Shifting visions: "delegation" policies and the building of a "rights-based" approach to maternal mortality.

"Rights-based" approaches fold human rights principles into the ongoing work of health policy making and programming. The example of delegation of anesthesia provision for emergency obstetric care is used to demonstrate how a rights-based approach, applied to this problem in the context of high-mortality countries, requires decision makers to shift from an individual, ethics-based, clinical perspective to a structural, rights-based, public health perspective. This fluid and context-sensitive approach to human rights also applies at the international level, where the direction of overall maternal mortality reduction strategy is set. By contrasting family planning programs and maternal mortality programs, this commentary argues for choosing the human rights approach that speaks most effectively to the power dynamics underlying the particular health problem being addressed. In the case of maternal death in high-mortality countries, this means a strategic focus on the health care system itself.

Cesarean Section↗