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PubMed2000

Sensitivity and perspective in the valuation of health status: whose values count?

The literature was studied on the existence of differences in valuation for hypothetical and actual health states between patients and other-rater groups. It was found that nine different study designs have been used to study this question and two of these designs were applied in a study involving dialysis patients and other rater groups. In the first study, both dialysis patients and students had to value hypothetical health states with Standard Gamble (SG) and Time Trade Off (TTO). Patients assigned higher values to hypothetical health states than students did. In the second study, dialysis patients who were being treated with four different dialysis modalities were asked to value their own health state with SG, TTO and a visual analogue scale (EQ(VAS)), and to describe their health state on the EQ-5D(profile). Several EQ-5D(index) values (health index values derived from general population samples) were calculated for the four dialysis treatment groups, based on the EQ-5D(profile). These health indexes could discriminate between treatment groups, according to clinical impressions. Treatment groups could not be differentiated based on patients' valuations of own health state. The results suggest that general population samples, using EQ-5D(index) values, may be more able to discriminate between patient groups than the patients themselves are. The implications of this finding for valuation research and policy-making are discussed.

Health Status Indicators↗

PubMed1999

State-of-the-art challenges for mental health services research.

BACKGROUND: Research-based, state-of-the-art services for people with serious mental disorders would consist of demonstrably effective treatments, organized synergistically, and financed in ways that create incentives to provide such treatment. While research exists in these domains of treatment, organization and financing, this research base contains significant gaps, and what is known frequently neither informs policy making nor enters practice. REVIEW: The NIMH services-research portfolio has identified successful patient-level and system-level interventions for people with serious mental disorders, but much of this research has yet to make its way into practice. Similarly, while we have made progress in asking "what is good care?", we have much less information about the answers to "what constitutes an adequate try?". Writing a prescription for an efficacious medication does not constitute an adequate trial of that medication. Similarly, offering people boring psychosocial rehabilitation programs does not constitute an adequate try of promoting recovery via rehabilitation services, but what does? Defining what constitutes an adequate try can be a way of allocating scarce resources or it can be a polite way of defining when a system gets to give up on someone. As state governments move to contract with managed care entities for services for Medicaid beneficiaries, one of the great contracting challenges is defining and monitoring the provision of what constitutes an adequate try. DISCUSSION: To obtain better value for our health care expenditures, we need to find ways to get what we know works into practice, whether we are contracting for services or deciding which clinical therapies to pursue. For example, problem-oriented family therapy has been shown to improve clinical outcomes for people with schizophrenia, yet such interventions are rare in practice. We also need to pay more attention to the quality of the clinical care actually being delivered - not what was prescribed, nor what the clinician was trained in, nor what the job description was, but what actually is occurring. Figuring out how to contract for and disseminate efficacious treatments so that they occur and are effective in real-world settings is critically important yet is a largely unexplored area of services research. We need to answer both "what is good care?" and "how do we get it to happen?".

Journal Article↗

PubMed2001

Capture-recapture estimation of unreported work-related musculoskeletal disorders in Connecticut.

BACKGROUND: Estimates of the extent of musculoskeletal disorders (MSD) are usually based upon workers' compensation reports, although recent reports indicate that there may be widespread under-reporting of MSD. METHODS: An estimate of the incidence of arm and hand work-related MSD was made using capture-recapture analysis of the overlap between state workers' compensation reports and physician reports in Connecticut for 1995. The resulting estimate was compared to a population-based survey of MSD. RESULTS: There was very small overlap between the two state injury reporting systems: 6.7% of 793 reported workers' compensation cases, or 8% of 661 physician's reports. The estimate for MSD not captured by either system was 13,285, resulting in 14,686 (95% CI: 9,733-18,453) total reported and non-reported cases. This compares to an estimate of 13,775 cases (95% CI: 8,800-18,800) based on a phone survey. CONCLUSIONS: This analysis points to substantial under-reporting of MSD in Connecticut: estimates of unreported cases exceed those officially reported by a factor of 11:1. The findings have an important bearing on injury prevention programs and policy making.

Connecticut↗

PubMed2004

Medical privacy and the disclosure of personal medical information: the beliefs and experiences of those with genetic and other clinical conditions.

There has been heightened legislative attention to medical privacy and to protections from genetic discrimination, without large-scale studies to document privacy concerns or analysis of whether experiences differ by whether the condition is genetic (defined here as a single-gene disorder) or non-genetic. To determine whether experiences regarding privacy, disclosure, and consequences of disclosure differ by whether one's medical condition is genetic, we conducted a descriptive study with one-time, structured quantitative and qualitative interviews. We interviewed approximately 100 adults or parents of children with each of the following medical conditions: sickle cell disease, cystic fibrosis, diabetes, and HIV, and 200 adults with or at risk for breast cancer or colon cancer. The percentages of the total 597 respondents experiencing positive or negative consequences of disclosure and the degree to which experiences differed by whether the condition was genetic were the outcomes of interest. Seventy-four percent were glad and 13% regretted others knew about their condition; these findings did not differ significantly by genetic vs. non-genetic condition. Reports of job and health insurance discrimination were not uncommon for the overall study population (19 and 27%, respectively) but were more likely among those with genetic conditions (30 and 37%, respectively). Legislation and other policy-making should target the needs of persons with all conditions and not focus exclusively on genetic discrimination, given that experiences and concerns generally do not differ based on the genetic etiology of the condition.

Adolescent↗

PubMed2006

Capacity to consent to research in schizophrenia: the expanding evidence base.

Capacity to consent to research, fundamental to informed consent and thus vital to the ethical conduct of research, may be impaired among a variety of research populations. Until recently, relatively little empirical evidence has been available to inform discussion and policy-making regarding whose capacity should be assessed, what should be measured, and how it should be measured. Capacity to consent to research has emerged as a central topic in the field of "empirical ethics," an important area of biomedical research devoted to bringing evidence-based methods to the study of ethically salient issues in biomedical and biopsychosocial research. In this paper, empirical studies of capacity to consent to research are reviewed, with a particular focus on studies involving people with schizophrenia. These studies provide intriguing data regarding the nature, correlates, and modifiability of decisional abilities among potentially vulnerable research populations, including individuals with serious neuropsychiatric illnesses. Areas in need of further empirical ethics research are highlighted.

Biomedical Research↗

PubMed2003

Teaching performance improvement: an opportunity for continuing medical education.

Practicing physicians generally are not engaged in either the methods of performance improvement for health care or the measurement and reporting of clinical outcomes. The principal reasons are lack of compensation for such work, the perception that the work of performance improvement adds no value and is a waste of time, the lack of knowledge and skill in the use of basic tools for outcomes measurement and performance improvement, the failure of medical educators to teach these skills, and the inability of mentors to model their use in practice. In this article, an overview of the history of quality improvement or performance improvement in general and the adoption of two methods of improvement (Plan-Do-Study-Act and SIX SIGMA) by health care is given. Six simple tools that are easy to understand and use and could be used in every continuing medical education (CME) program are then explained and illustrated. Postgraduate medical educators and CME program directors must step up to the challenge of teaching these skills. By learning to include them in planning, evaluation, policy making, and needs assessments of CME programs, the skills of every physician could be improved. Additional goals of every CME program could be accountability for outcomes, reduction of errors, alignment of incentives, and advocacy for the very best in evidence-based health care. To develop activities that affect physician practice and population health, CME professionals must partner with performance improvement experts for needs assessment and evaluation of outcomes data. An understanding of performance improvement principles helps those in performance improvement and those in CME to determine which educational activities might be expected to influence physician competency and performance.

Clinical Competence↗

PubMed1986

Philosophical considerations in health professions continuing education.

Health professions continuing education is in a state of sprawling disarray. Much of this chaos can be attributed to a lack of clarity regarding its goals and purposes. A historical-philosophical analysis of the aims of continuing education for the health professions provides the basis for clarifying its major goal orientations. Application of this paradigm to practice helps explain underlying variations in the values, beliefs and premises currently characterizing health professions continuing education and can provide sound direction to those responsible for programmatic and policy-making decisions.

Education, Continuing↗

PubMed1999

Nonpharmacologic therapies that reduce blood pressure: a fresh perspective.

Traditional approaches to control the epidemic of blood pressure-related atherosclerotic cardiovascular disease (ASCVD) have largely focused on drug therapy in persons with hypertension. Still, nonpharmacologic therapy, also termed lifestyle modification, has an important and expanding role that complements drug therapy. Specifically, nonpharmacologic therapies can serve as initial therapy in Stage 1 hypertensive patients, facilitate medication step down or withdrawal in patients with well-controlled hypertension, prevent hypertension in high-risk populations, and reduce blood pressure in normotensive individuals and thereby lower their risk of ASCVD. Traditional lifestyle modifications that reduce blood pressure include sodium reduction, weight loss, moderation of alcohol intake, and increased physical activity. Such strategies have been prominently advocated in the Fifth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Recommendations to increase potassium, magnesium, and calcium intake were based primarily on general health considerations, not for control of high blood pressure. In its sixth and most recent report (JNC VI) published in 1997, the Joint National Committee has extended its recommendations. In addition to the traditional lifestyle recommendations, the JNC VI advocates increased potassium intake for control of high blood pressure. Furthermore, this policy-making body now recommends a healthy dietary pattern, that is, one that is rich in fruits, vegetables, and low-fat dairy products, and reduced in saturated fat, total fat, and cholesterol. This diet, which was rigorously evaluated in the Dietary Approaches to Stop Hypertension (DASH) clinical trial, substantially lowered blood pressure in normotensive and hypertensive individuals. These recent developments reinforce the hypothesis that multiple dietary factors influence blood pressure. Nonpharmacologic approaches have enormous potential as a means to reduce blood pressure and control hypertension, thereby preventing the occurrence of ASCVD. The current challenge to health care providers, government officials, and the general public is to develop and implement effective clinical and public health strategies that lead to desirable lifestyle modifications.

Blood Pressure↗

PubMedDate not supplied

Central and local control in Nordic health care: the public organisation spectrum revised.

One of the distinguishing characteristics of national health care systems is the degree of public involvement in service provision, funding and policy making. In international comparisons the Nordic countries are usually seen as a uniform group. Yet, the countries do have important differences, and a descriptive model was sought to demonstrate these, and, at the same time, to differentiate the concept of public control. Using the central-local dichotomy, differences within the public framework were demonstrated between the countries, e.g. in methods of funding, financial regulation, formal planning instruments, and control of resource allocation. Financial control and planning were identified as two distinct components of public control. An analysis of the degree of centralisation along both dimensions separated the Nordic countries, which are otherwise homogenous as to public sector dominance.

Decision Making, Organizational↗

PubMedDate not supplied

Decentralization and health care in the former Yugoslav Republic of Macedonia.

Since its independence in 1991, the Republic of Macedonia became a highly centralized state, with most relevant decisions taken at the central level in Skopje, resembling the highly centralized system, which once characterized Former Yugoslavia. As agreed in the Framework Agreement, which ended six months of internal conflict, the Macedonian Government will decentralize public services delivery, including social protection, health, education, and infrastructure over the course of the next few years. Within health care, it is argued that by placing policy-making authority and operating control closer to the client, decentralization will reduce some of the inequities in service provision and inefficiencies present within the current centrally controlled system. In principle, local voters will have more information on the price and quality of services, thereby increasing competition in the sector and strengthening the private sector. The emphasis on market incentives resulting in greater efficiency and better management of health care institutions is viewed as one of the benefits of privatization. Critics of decentralization and the subsequent privatization of public services fear it may result in an erosion of quality and consistency across regions, leaving some regions, cities, villages and potentially vulnerable groups worse off than others. The paper argues that if the institutional weaknesses in Macedonia have not been addressed, decentralisation could result in further excluding the rural population from health care provision. Similarly, the need for a clear delineation of responsibilities and functions among different levels and institutions is outlined.

Delivery of Health Care↗

PubMedDate not supplied

Whither managerialism in the Italian National Health Service?

In the last decade, the Italian National Health Service has been characterized by the introduction of managerial concepts and techniques, according to the New Public Management paradigm. Recently, these reforms have been increasingly criticized. This article examines the implementation of managerialism in an attempt to evaluate its overall achievements and shortcomings. Overall, managerialism seems to have made good progress: managerial skills are improving; several management tools have been adapted to health-care and public-sector peculiarities; health-care organizations have adopted a wide range of technical solutions to fit their specific needs. At the same time, managerial innovations have often focused on structures as opposed to processes, on the way the organization looks as opposed to the way it works, on the tools it has as opposed to those it actually needs and uses. We thus suggest that research, training and policy-making should stop focusing on the technical features and theoretical virtues of specific tools and should redirect their emphasis on change management.

Efficiency, Organizational↗

PubMed1992

Could your hospital benefit from an owner-controlled insurance program?

In summary, underwriters are reaching out to consider some construction projects that are traditionally too small to qualify for an OCIP (under $80,000,000). A hospital system with an ongoing capital expenditures budget in excess of $100,000,000 over any three-year period can group its construction projects together to meet the minimum qualifying amounts generally required by underwriters for the OCIP. The approach of wrapping up the coverage for all the contractors on-site into one policy makes good economic sense and is administratively manageable with the computer support systems available from some brokers today. The concentrated effort of loss prevention, coupled with the control factor of knowing how much insurance is available and the security of the insurer providing it, makes for a winning combination in addressing the unknown risk brought on by large construction projects at the hospital.

Contract Services↗

PubMedDate not supplied

The new cell culture smallpox vaccine should be offered to the general population.

A series of major factors must be weighed in deciding whether or not, and to what extent, a particular country should consider pre-exposure vaccination for smallpox. These include the risk of a bioterrorist attack using smallpox, the risk of secondary spread from another country, the risks and benefits of vaccination, the effectivenes s of vaccination pre- and post-exposure, the prevalence of immunocompromised persons, the capacity of the medical care delivery system and the wealth of a nation. We review here the issues and variables relevant for policy making, propose a framework for country-specific decision making and suggest the World Health Organization has a key role to play, particularly with regard to lower-income countries. In doing so, we support the proposition.

Bioterrorism↗

PubMed2000

General equilibrium of an ecosystem.

Ecosystems and economies are inextricably linked: ecosystem models and economic models are not linked. Consequently, using either type of model to design policies for preserving ecosystems or improving economic performance omits important information. Improved policies would follow from a model that links the systems and accounts for the mutual feedbacks by recognizing how key ecosystem variables influence key economic variables, and vice versa. Because general equilibrium economic models already are widely used for policy making, the approach used here is to develop a general equilibrium ecosystem model which captures salient biological functions and which can be integrated with extant economic models. In the ecosystem model, each organism is assumed to be a net energy maximizer that must exert energy to capture biomass from other organisms. The exerted energies are the "prices" that are paid to biomass, and each organism takes the prices as signals over which it has no control. The maximization problem yields the organism's demand for and supply of biomass to other organisms as functions of the prices. The demands and supplies for each biomass are aggregated over all organisms in each species which establishes biomass markets wherein biomass prices are determined. A short-run equilibrium is established when all organisms are maximizing and demand equals supply in every biomass market. If a species exhibits positive (negative) net energy in equilibrium, its population increases (decreases) and a new equilibrium follows. The demand and supply forces in the biomass markets drive each species toward zero stored energy and a long-run equilibrium. Population adjustments are not based on typical Lotka-Volterra differential equations in which one entire population adjusts to another entire population thereby masking organism behavior; instead, individual organism behavior is central to population adjustments. Numerical simulations use a marine food web in Alaska to illustrate the model and to show several simultaneous predator/prey relationships, prey switching by the top predator, and energy flows through the web.

Animals↗

PubMed1993

Knowledge, attitudes, and personal practices regarding prevention and early detection of cancer.

METHODS: To determine population knowledge, attitudes, and personal practices regarding prevention and early detection of cancer, random population samples of 25- to 74-year-old men and women in six various-sized communities in three upper-midwestern states (N = 4,915) were administered surveys and interviews during 1987-1989. RESULTS: Four-fifths of respondents believed cancer to be preventable. Knowledge of warning signs/symptoms of cancer and of leading causes of cancer, however, was low. Over 95% of women had had a Papanicolaou smear and a clinical breast exam or had performed a breast self-exam; 65.7% of those ages 50-65 years had had a mammogram. Among men and women ages 50-65 years, 77% had had a digital rectal exam; 52.5%, a fecal occult blood test; and 48.3%, a sigmoidoscopy. CONCLUSIONS: Conditions are favorable for an increase in mammography, including favorable attitudes toward cancer prevention, strong consensus among policy-making organizations regarding guidelines for obtaining mammograms, and high levels of adherence to these recommendations by women who have had at least their first mammogram. Challenges now include acceptance of these guidelines by physicians, mammogram affordability/availability, and demonstration of efficacious, cost-effective, and reliable colorectal/prostate cancer screening tests.

Adult↗

PubMed1983

Systems planning for the 80s: the Nebraska Mental Health Desired Service System model.

In an effort to address the complex realities of mental health service delivery in the 1980s, a systems model for planning and policy making has been developed. The model, called "the Nebraska Mental Health Desired Service System," can serve as a template for future service delivery system design. The development of the model and issues attendant to it are presented. Application of the model to planning, fiscal management, system management, politics, human resources development, and services coordination is presented.

Health Planning Organizations↗

PubMed1989

Children's mental health services: a parent perspective.

Parents of severely emotionally and behaviorally disturbed children rarely have the opportunity to participate in the policy-making processes that affect their children's welfare. In the present study, a structured parent interview was developed as part of Washington State's Child and Adolescent Services System Program (CASSP). Thirty-five parents of disturbed children provided information about their children's problems and services histories. Respondents identified unmet needs and barriers to timely, effective intervention. The nature and quality of services received were examined in the context of CASSP service standards. The study confirmed that parents of disturbed children can provide information rich in implications for system change.

Adolescent↗

PubMed1990

Meeting the needs of people with psychiatric disorders.

Evaluative research into the provision of psychiatric services to communities and individuals covers the whole spectrum of diagnosis, treatment and care, and the apparatus of policy-making, administration and management concerned in 'delivery'. The problems for research are described in terms of two central concepts--social disablement and need. Emphasis is placed on the importance of a needs assessment system, in spite of the methodological problems it poses. Examples are drawn chiefly from the UK National Health Service (NHS) because of the opportunities it provides for epidemiologically based research, but the issues raised are universal.

Community Mental Health Services↗