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PubMed1996

A way to approach the strategic decisions facing academic health centers.

Rapid changes taking place in the various markets served by academic health centers (AHCs) are forcing these institutions to make difficult strategic decisions that may change AHCs' historic priorities. The authors present an approach that can help AHCs visualize possible new configurations of their traditional services of research, education, and clinical care. This approach is based on successful strategic management methods from the private sector and involves a three-dimensional "topography of services" encompassing all possible configurations of AHCs' services. From among the many possible configurations, the authors discuss three in detail. The historic one, which they call the traditional model, is characteristic of AHCs that give high priority to biomedical and clinical research, have broad medical education activities, and deliver comprehensive, high-quality clinical care. In the future, this configuration will be rare, and two others are likely to predominate. First is the "revised" traditional model, which would offer "boutique" clinical services, biomedical research, and medical education for MD-PhD students, residents, and fellows seeking tertiary care or academic careers. The patient care required for undergraduate medical education and clinical research would be provided by partnerships with community-based providers. Second is the academic services model, which would focus on competitive primary and secondary clinical services, health services and operations research, and primary care medical education. The authors discuss the implications of these models for AHCs' organizational structures and faculty incentives. They conclude that the clarity with which AHCs' strategic decisions are made and communicated to faculties and the incentive systems that are selected to motivate faculty and to provide the selected services may ultimately determine which institutions survive.

Academic Medical Centers↗
PubMed1990

Enhancing your ethical reasoning.

There is nothing a nurse does more frequently than make decisions, and in intensive care most of these decisions have ethical ramifications. Critical care nurses and other health care professionals must be more effectively prepared to resolve the complex ethical problems that are a natural by-product of health care in the 1990s. Each of us has an obligation as a patient advocate to use a systematic decision-making process, not just an emotive one, when faced with difficult ethical dilemmas. This article presents a decision-making process that is based on the steps of the nursing process, the theories of deontology and utilitarianism, and the strengths in the steps of the valuing process. A difficult case is shared at the end of the article that challenges the reader to examine his or her decision-making capabilities from a systematic and ethical perspective.

Adult↗
PubMed1996

Health care management of children with cognitive and physical disabilities: to treat or not to treat.

Advanced medical technology has provided life support and maintenance for high risk infants. In dramatically increasing numbers, children surviving aggressive intervention as neonates and infants suffer from varying degrees of physical and mental disability. Once these children are stable and grow older difficult medical intervention decisions need to be made. As nurses, we are often in situations involving difficult treatment decisions made by the family and health care team. We need to be aware of our personal beliefs and ethical principles to effectively support family members and participate in decision making. Ethical principles serve as a guide to the decision making process.

Child↗
PubMed2002

Should rationing of health care be explicit?

The aim of this paper is to discuss whether medical professionals should inform patients that there may be drugs or procedures that would benefit them., but which the National Health Service cannot afford to provide. The main body of the paper examines the argument put forward by Professor David Hunter who suggests that rationing of health care should be implicit. I will argue that his arguments are unconvincing. Some of the reasons that Coast and Mechanic give support to implicit rationing of health care are looked at briefly and similarly found to be wanting. In our present culture openness is encouraged from doctors. It is also acknowledged by the medical profession that patients' autonomy should be respected. The importance of autonomy is emphasised in the teaching of our medical students. My submission will be that it is difficult to see how patients' autonomy can properly be exercised unless they are told that treatment is being refused to them that might help their condition.

Decision Making↗
PubMed2006

Ethical issues in neonatal intensive care and physicians' practices: a European perspective.

UNLABELLED: An international project (EURONIC) was carried out to explore the end-of-life decision-making process in a large, representative sample of neonatal intensive care units (NICUs) in eight western European countries: France, Germany, Great Britain, Italy, Luxembourg, the Netherlands, Spain and Sweden. Structured questionnaires were used to record data on NICU organization and policies, and to survey staff views and practices regarding ethical decision-making. One hundred and twenty-two NICUs were recruited by census or random sampling (response rate 86%); 1235 physicians and 3115 nurses completed the staff questionnaire (response rates 89 and 85%, respectively). This paper focuses on the physicians' answers. In all countries but Italy, most physicians reported having been involved at least once in setting limits to intensive care because of a baby's incurable condition and/or poor neurological prognosis. Adopted strategies varied between countries. Practices such as the continuation of current treatment without intensifying it and the withholding of emergency manoeuvres appeared widespread. In contrast, the frequency of doctors reporting withdrawal of mechanical ventilation was highest in the Netherlands (93%), Sweden (91%) and the Great Britain (88%), intermediate in France and Germany, and lowest in Spain and Italy (34 and 21%, respectively). CONCLUSION: Ethically problematic clinical cases are approached differently in the various countries. The findings of this study may provide an opportunity for physicians to review their practices critically, in light of how other colleagues proceed, and foster an open discussion about these difficult issues.

Adult↗
PubMed1989

[Request for a hemogram as a marker of the quality of health care].

The evaluation of markers of the health care activity, such as the reason for requesting a peripheral blood count in everyday practice and its inclusion in the clinical record, constitutes an estimate of the quality of care. To this end, we have reviewed the requests of 160 peripheral blood counts in our center during one month. It was found that the request itself and/or its cause had not been mentioned in the clinical record in 32.5% of instances. In the cases where the indication could be ascertained, it was not justified in 58.4%. Overall 72.5% of peripheral blood counts were normal. It was concluded that peripheral blood count is an over-utilized test, while its request is insufficiently recorded. This makes diagnostic decisions and the evaluation of the quality of care difficult.

Blood Cell Count↗
PubMed2002

Rationalising rationing: economic and other considerations in the debate about funding of Viagra.

Although the cost-effectiveness of Viagra for the treatment of patients with erectile dysfunction is favourable, both public and political opinions seem to be inclined not to fund, or merely to partially fund (i.e. by reimbursing only specific patient groups) this medicine. This shows that in funding discussions, cost-effectiveness information is not solely decisive. In a theoretical framework for choices in health care that was developed in The Netherlands (the Dunning report, 1991), two other criteria besides cost-effectiveness were put forward as being important for rationing decisions: "necessary care" and "individual responsibility". Overlooking the Viagra discussion, many of the arguments put forward seemed to be related to these two criteria. However, a clear operationalisation of the criteria necessary care and individual responsibility is lacking, which makes it difficult to use the arguments in funding decisions. In this paper, we try to demonstrate how these criteria were presented in the Viagra discussion and we will indicate how these criteria can be operationalised in relation to the outcomes of a cost-effectiveness analysis.

Cost-Benefit Analysis↗
PubMed1992

Caring for older cancer patients: practical decision-making guidelines with a focus on advance directives.

There are no simple solutions to difficult ethical problems. Advance directives, however, offer a way to help prevent ethical dilemmas from occurring in the care of older cancer patients. Studies show that there is overwhelming support from both older patients and physicians for advance treatment planning through the use of living wills, durable powers of attorney for health care, and less formal means. Despite this support, few physicians and patients discuss advance directives. This paper discusses potential barriers to this dialogue and suggests specific ways to incorporate advance directive into routine cancer care of older patients. The Patient Self-Determination Act of 1990 represents additional pressure from society on the medical profession to carry out advance directive discussions.

Advance Directives↗
PubMed2004

Quality of life is a primary end-point in clinical settings.

The objective of this review is to present and discuss the quality of life (QOL) construct, more specifically the QOL in the field of health and disease also designated as health-related quality of life (HRQOL). QOL is an everyday language concept with a relatively short history in the health field. It became a principal end-point in health care as a consequence of the development of patients' rights movements. It is important for clinical, economic and political decisions. There is no gold standard way to measure QOL and the existence of a huge number of measures and related QOL concepts makes it difficult to discuss QOL. This means that many times we are using the same expression "QOL" but we are not talking about the same thing. So we submit that it is important to keep looking for the good construct and the good measure. The reason why we decide to evaluate QOL influences the measures we choose. In general, QOL measures are based on questionnaires that must be short and easy to answer. The interest in these kind of soft measures (in opposition to the traditional hard physiologically or biochemically oriented measures) is growing fast.

Activities of Daily Living↗
PubMed1994

Values clarification and ethical decision making.

Ethical decision making at the bedside has become an integral part of nursing care delivery. Health care providers have long been practicing clinical ethics as evidenced by their codes of practice. Still, bedside ethical decision making has really just become more formalized in the 1980s through the establishment of hospital ethics committees. The decisions of the 1980s and 1990s have become more difficult as well mostly because of advanced medical technology, the increased number of people now involved in the decision-making process, and most importantly, the recognition of patient autonomy in the decision-making process.

Advance Directives↗
PubMed1983

Clinical implications of population-based studies in Europe.

The cross-fertilization of epidemiology and clinical medicine is a continuous process. The impressive progress in cardiovascular disease (CVD) epidemiology of the last 30 years was substantially reinforced by large population-based intervention studies in the last decade. As a result, guidelines for prevention are emerging with relatively clear implications for clinical medicine in general. Two such guidelines were recently published by the Royal College of General Practitioners (2, 5). However, the application of these general principles in day-to-day doctor-patient interaction is not easy. General health promotion counseling in the family, conscientious case findings, and regular follow-up are the main points of agreement between epidemiologists and progressive clinicians. Preventive treatment with drugs, however, needs to be decided in each case individually. The ever-increasing new epidemiological knowledge, the intimate knowledge of the individual and his family, and the careful balancing of potential benefits and possible side effects of treatment coupled with the art of the clinician are helping physicians to make these difficult decisions correctly. In order to maximally diminish the current need for such difficult decision making, when the patient's risk is already high, generally adopted, sound, and safe health promotion efforts should be pursued by clinicians in their everyday activities. WHO will continue to encourage the accumulation of sound knowledge in prevention of CVD and other chronic diseases. The future calls for comprehensive health promotion policies focused on the individual and on the community, not only in regard to single diseases.

Coronary Disease↗
PubMed2006

Vulnerable populations: cultural and spiritual direction.

Cultural, spiritual, and religious diversity of emergency department patients is increasing while that of emergency physicians in particular remains predominantly homogeneous. With a discordance of cultural, race, and ethnicity exist, in the case of ethical conflict -resolution becomes that much more difficult. Patients may feel vulnerable when their emergency care provider does not understand his or her cultural, spiritual, and religious uniqueness as it relates to the patient-doctor interaction and health care decision making. This review will examine (1) language differences; (2) cultural, religious, and spiritual differences between patient and provider; (3) differing explanatory models of disease between patient and provider; and (4) diverse bioethical models of decision making of differing cultures in an effort to reduce vulnerabilities.

Cultural Diversity↗
PubMed2004

Successful adherence after multiple HIV treatment failures.

BACKGROUND: Non-adherence to human immunodeficiency virus (HIV) medications often results in irreparable drug resistance and poor outcomes. Hence, care providers generally think that treatment of HIV disease should be delayed until a person is 'ready' to adhere. However, little research has focused on understanding the process that results in readiness for successful adherence. AIM: The aim of this phenomenological study was to describe and understand the experience and decision-making processes of people who became adherent to their HIV medication regimens after previously failing treatment because of non-adherence. METHOD: A Husserlian phenomenological approach was taken, and in-depth interviews were analysed using Giorgi's method of phenomenological description and analysis. FINDINGS: Thirteen HIV-positive men and women who had previously failed two or more treatment regimens because of non-adherence were purposefully selected from two infectious diseases clinics in the Midwest region of the United States. They had achieved and sustained adherence to their HIV medications for 1 year or longer without formal intervention. All participants experienced a 'trigger' event preceding the process that led to the ability to incorporate lifestyle and health behaviour changes necessary for successful adherence. Factors associated with the process leading to adherence were: changing attitudes towards HIV medication, finding the right health care provider, creating the right support system, getting control of life and having goals. CONCLUSIONS: This study demonstrated that HIV-positive individuals who had been non-adherent and had been viewed as 'difficult to treat' nonetheless successfully adhered to treatment once they became 'ready'. Findings from this study implicate that readiness may be a necessary component for successful adherence, particularly in HIV-positive individuals who have previously failed treatment. Understanding the relationship between the phenomenon of readiness and subsequent HIV treatment adherence has implications for clinical decision-making and for development of interventions that enhance adherence and prevent HIV drug resistance.

Adult↗
PubMed2006

Mental health integration: rethinking practitioner roles in the treatment of depression: the specialist, primary care physicians, and the practice nurse.

Although primary care provides the majority of mental health care, lack of time and documented economic benefit make it difficult for healthcare delivery systems to proactively implement effective treatment strategies for the growing disability of depression. Current care delivery models are inadequate and inefficient, leading to provider and consumer exhaustion, as well as significant gaps in care and poor outcomes. This publication describes a quality improvement pilot demonstration called "mental health integration" (MHI) that has been successful in realigning resources, enhancing clinical decision making, measuring the impact and building a business case to determine what actually is the value added for quality. Mental health integration (MHI) promotes the rethinking and retraining of traditional solo practitioner roles to new practitioner roles that facilitate partnership and effective communication as a means to help patients and families achieve a state of successful performance. Results describe the improvements in depression detection at a neutral or lower cost to the health plan. Recommendations are identified for building the business case for MHI quality in order to sustain improved outcomes and promote diffusion of the model outside of Intermountain Health Care (IHC) setting.

Delivery of Health Care, Integrated↗
PubMed1990

Board chairman John Makel on cutting services versus diversification. Interview by Karen Gardner.

John Makel, chairman of the board of the Memorial Health Alliance of Mount Holly, NJ, and vice-president and regional trust office manager, First Fidelity Bank, NA-New Jersey, Moorestown, began his tenure on the board of the Memorial Hospital of Burlington County, NJ, in 1975. He has been chairman of the alliance since 1983. Makel has been involved in diversification and divestment decisions since 1979, when the alliance was formed. It now includes a 402-bed acute care hospital--the Memorial Hospital of Burlington County--a 120-bed long-term care facility, and a home health care agency that makes approximately 70,000 home care visits a year The alliance's 30-member board, under the active leadership of a 13-member executive committee, governs each of the three affiliates. Recently, Trustee managing editor Karen Gardner talked with Makel to learn how the board has approached the difficult decisions involved in cutting services versus diversification.

Governing Board↗
PubMed2002

Cost analysis of magnetic resonance cholangiography in the management of inoperable hilar biliary obstruction.

OBJECTIVE: Palliation of patients with Klatskin tumors involving both hepatic ducts is usually performed with bilateral biliary stent placement. Magnetic resonance cholangiopancreatography (MRCP) offers the ability to visualize the hepatic ducts without injection of contrast, thereby reducing the patient's risk of developing postprocedure bacterial cholangitis. We used decision analysis techniques to quantitate the cost-effectiveness of MRCP before stent placement versus routine placement of bilateral biliary stents in the setting of inoperable malignant hilar obstruction. In addition to determining which strategy was most economical, we used sensitivity analysis to identify the critical factors defining relative costs. METHODS: A decision analysis model was designed comparing MRCP with subsequent unilateral biliary stent placement and double biliary stent placement approaches for palliation of jaundice in a patient with inoperable malignant hilar obstruction, as viewed from the societal perspective. Baseline probabilities, obtained from the published literature, were varied through plausible ranges using sensitivity analysis. Charges were based on Medicare professional plus facility fees or diagnosis-related group rates for out- and inpatients, respectively. RESULTS: MRCP with subsequent directed unilateral stent placement was the least costly approach ($3806) compared with bilateral stent placement ($4275), provided the bilateral biliary stent complication rate was >3%. Bilateral stent placement needed to confer a survival advantage of at least 7 days over unilateral stent placement to become the more cost-effective approach. CONCLUSIONS: The use of MRCP to guide biliary stent placement in a patient with inoperable hilar obstruction reduces the overall cost of treatment. The uncertainty of any survival advantage that bilateral biliary stent placement confers over unilateral stent placement makes cost-effectiveness difficult to assess.

Cholangiography↗
PubMed2003

Beliefs and expectations of women under 50 years old regarding screening mammography: a qualitative study.

OBJECTIVE: Because shared decision making has been recommended for screening mammography by women under age 50, we studied women's decision-making process regarding the procedure. DESIGN: Qualitative research design using in-depth semi-structured interviews. PATIENTS: Sixteen white and African-American women aged 38 to 45 receiving care at a large New England medical practice. MEASUREMENTS AND MAIN RESULTS: We identified the following content areas in women's decision-making process: intentions for screening, motivating factors to undergo screening, attitudes toward screening mammography, attitudes toward breast cancer, and preferences for information and shared decision making. In our sample, all women had or intended to have a screening mammogram before age 50. They were motivated by the awareness of the recommendation to begin screening at age 40, knowing others with breast cancer, and a sense of personal responsibility for their health. Participants feared breast cancer and thought the benefits of screening mammography far outweighed its risks. Women's preferences for involvement in decision making varied from wanting full responsibility for screening decisions to deferring to their medical providers. All preferred the primary care provider to be the main source of information, yet the participants stated that their own providers played a limited role in educating them about the risks and benefits of screening and the mammography procedure itself. Most of their information was derived from the media. CONCLUSIONS: The women in this study demonstrated little ambivalence in their desire for mammography screening prior to age 50. They reported minimal communication with their medical providers about the risks and benefits of screening. Better information flow regarding mammography screening is necessary. Given the lack of uncertainty among women's perceptions regarding screening mammography, shared decision making in this area may be difficult to achieve.

Adult↗