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PubMed2003

A comparison of single- and multi-payer health insurance systems and options for reform.

A major choice confronting many countries is between single-payer and multi-payer health insurance systems. This paper compares single-payer models in the areas of revenue collection, risk pooling, purchasing, and social solidarity. Single-payer and multi-payer systems each have advantages which may meet countries' priorities for their health insurance system. Single-payer systems are usually financed more progressively, and rely on existing taxation systems; they effectively distribute risks throughout one large risk pool; and they offer governments a high degree of control over the total expenditure on health. Multi-payer systems sacrifice this control for a greater ability to meet the diverse preferences of beneficiaries. Several major reforms of single-payer insurance systems--expansion of the role of private insurance and transformation to a multi-payer system--are then described and illustrated using specific country examples. These reforms have been implemented with some success in several countries but face several important challenges.

Consumer Behavior↗

PubMedDate not supplied

Commentary on the Bates et al. report on eye-movement desensitization and reprocessing (EMDR)

In their 1996 paper, Bates, McGlynn, Montgomery, and Mattke were critical of eye-movement desensitization and reprocessing (EMDR) as an effective method of behavior therapy. The present commentary challenges the Bates et al. review of the literature, and the implementation of EMDR used in reaching their conclusions. Evidence is offered to support the clinical use of EMDR.

Clinical Protocols↗

PubMed2005

Mental health care in Madrid.

AIM: To describe principles and characteristics of mental health care in Madrid. METHOD: Based on existing data, service provision, number of professionals working in services, funding arrangements, pathways into care, user/carer involvement and specific issues are reported. RESULTS: In Madrid, mental health services are organized into 11 zones/areas, divided into 36 districts, where there is a mental health outpatient service with a multi-disciplinary team. Home treatment and psychosocial rehabilitation services have been developed. Specialist programmes exist for vulnerable client groups, including Children and Adolescents, Addiction/Alcohol and Older People. The Madrid Mental Health Plan (2003-2008) is regarded as the key driver in implementing service improvement and increased mental health and well-being in Madrid. It has a meant global budget increase of more than 10% for mental health services. Results of the first 2 years are: an increase in mental health staff employed (17%), four new hospitalization units, 50% increase in places for children and adolescents Day Hospitals, 62 new beds in long care residential units, development of specific programmes for the homeless and gender-based violence, a significant investment in information systems (450 new computers) and development of best practice and operational guidelines. Mental health system was put to the test with Madrid's March 11th terrorist attack. A Special Mental Health Plan for Affected people was developed. DISCUSSION: Unlike some European countries, public mental health service is the main heath care provider. There are no voluntary agencies bcollaborating with mental health care. Continuity of care and coordination between all mental health resources is essential in service delivery. Increased demand of care for minor psychiatric disorders, children and adolescent mental health care, and implementation of rehabilitation and residential facilities for chronic patients are outstanding challenges similar to those in other European capitals. Overall, the mental health system had successfully coped with last year's increased care demand after March 11th terrorist attack in Madrid.

Adolescent↗

PubMedDate not supplied

Applying managed care performance measures in community pharmacy-based outcomes research.

OBJECTIVES: (1) To introduce the National Committee on Quality Assurance's (NCQA's) Health Employer Data and Information Set (HEDIS), a set of managed care performance measures, as a tool for conducting outcomes research in the community pharmacy; (2) To demonstrate the practical application of this tool by describing three outcomes research projects conducted in an independent community pharmacy. DESIGN: Review of three outcomes research projects based on HEDIS: (1) Increasing ACEI Use in Patients with Heart Failure, (2) Cardiovascular Telepharmacy Project, and (3) Pediatric Antibiotic Callback Program. SETTING: Independent community pharmacy. RESULTS: The "Effectiveness of Care" section of HEDIS was a practical tool for designing outcomes research projects in the community setting. Improved clinical and/or service outcomes were observed in two of the projects. The challenges faced in these projects were due to the methods of implementation, rather than to the HEDIS tool itself. These projects led to a number of "lessons learned" in the conduct of outcomes research in the community pharmacy setting. CONCLUSION: Community pharmacists can use NCQA's HEDIS as a tool to help gain acceptance of and reimbursement for pharmaceutical services through the formulation of outcomes projects that are of interest to managed care organizations (MCOs) seeking accreditation status. As pharmacists report their successes to MCOs, they may be better equipped to develop reimbursement strategies for services from MCOs through their demonstration of shared goals.

Angiotensin-Converting Enzyme Inhibitors↗

PubMedDate not supplied

International nursing education: challenges and strategies for success.

The Nursing Education Partnership Program between Nell Hodgson Woodruff School of Nursing at Emory University and Foo Yin Junior College of Nursing and Medical Technology in Taiwan is in its third year. This program provides an opportunity for associate-degree nurses from Taiwan to earn a bachelor of science degree in nursing. The educational challenges, inherent in such a program, became evident early in the first semester. This article outlines those challenges and the educational strategies that were successful with this group. Implementation of the curriculum reflects four culturally significant aspects of the educational process: identifying community resources to meet basic needs for adaptation to a foreign country; redesigning teaching and learning strategies for international students; preparing faculty, clinical agency staff, patients, and other students to accept and become actively involved in this international program; and developing faculty-student relationships that promote mentoring and foster professional role development. Although the strategies presented were used with a group of students from Taiwan, they also can meet the needs of other international students.

Community Participation↗

PubMed2002

Topologically protected quantum bits using Josephson junction arrays.

All physical implementations of quantum bits (or qubits, the logical elements in a putative quantum computer) must overcome conflicting requirements: the qubits should be manipulable through external signals, while remaining isolated from their environment. Proposals based on quantum optics emphasize optimal isolation, while those following the solid-state route exploit the variability and scalability of nanoscale fabrication techniques. Recently, various designs using superconducting structures have been successfully tested for quantum coherent operation, however, the ultimate goal of reaching coherent evolution over thousands of elementary operations remains a formidable task. Protecting qubits from decoherence by exploiting topological stability is a qualitatively new proposal that holds promise for long decoherence times, but its physical implementation has remained unclear. Here we show how strongly correlated systems developing an isolated twofold degenerate quantum dimer liquid ground state can be used in the construction of topologically stable qubits; we discuss their implementation using Josephson junction arrays. Although the complexity of their architecture challenges the technology base available today, such topological qubits greatly benefit from their built-in fault-tolerance.

Journal Article↗

PubMed2001

Data collection with adolescents.

Adolescence spans a wide time period during which development and its context influence behaviour and the strategies used for data collection. This article addresses problems that can be anticipated in data collection with adolescents. Problems are presented that are associated with adolescent developmental capacities, adolescent developmental change and stability, gender and ethnicity. Some problems are specific to certain settings or to certain data collection methods. The application of theoretical and empirical knowledge about adolescent development can strengthen data collection instruments and procedures. Strategies to enhance data collection include carefully defining adolescence and tailoring procedures and protocols based on a theoretical understanding of the biological, cognitive and emotional development of adolescents in conjunction with an understanding of the characteristics of the research setting. Adolescent research settings can pose challenges. Investigators must understand clinic routines in evaluating the feasibility of implementing protocols and collecting data where there are distractions and time constraints. In education settings, strategies must be used to collect data in a group context where peer pressure can affect responses. In home settings, ingrained response patterns and family norms can also impede obtaining valid perspectives from adolescents. Ethnicity as well may play an important role that must be addressed when designing and implementing data collection with adolescents. Procedures and instruments selected to collect data need to address variations in ethnicity.

Adolescent↗

PubMedDate not supplied

Management of herbicide-tolerant oilseed rape in Europe: a case study on minimizing vertical gene flow.

The potential commercialization of genetically modified herbicide-tolerant (GMHT) oilseed rape in Europe raises various concerns about their potential environmental and agronomic impacts, especially those associated with the escape of transgenes. Pollen of oilseed rape can be dispersed in space, resulting in the fertilization of sympatric compatible wild relatives (e.g. Brassica rapa) and oilseed rape cultivars grown nearby (GM and/or non-GM Brassica napus). The spatial and temporal dispersal of seeds of oilseed rape may lead to feral oilseed rape populations outside the cropped areas and oilseed rape volunteers in subsequent crops in the rotation. The incorporation of a HT trait(s) may increase the fitness of the recipient plants, making them more abundant and persistent, and may result in weeds that are difficult to control by the herbicide(s) to which they are tolerant. Vertical gene flow from transgenic oilseed rape to non-GM counterparts may also have an impact on farming and supply chain management, depending on labelling thresholds for the adventitious presence of GM material in non-GM products. Given the extent of pollen and seed dispersal in oilseed rape, it is obvious that the safe and sound integration of GMHT oilseed rape in Europe may require significant on-farm and off-farm management efforts. Crucial practical measures that can reduce vertical gene flow include (1) isolating seed production of Brassica napus, (2) the use of certified seed, (3) isolating fields of GM oilseed rape, (4) harvesting at the correct crop development stage with properly adjusted combine settings, (5) ensuring maximum germination of shed seeds after harvest, (6) controlling volunteers in subsequent crops, and (7) keeping on-farm records. The implementation of the recommended practices may, however, be difficult, entailing various challenges.

Agriculture↗

PubMed2001

Preventing vertical HIV transmission in the year 2000: progress and prospects--a review.

In the USA, progress in the ability to eliminate vertical HIV-1 transmission that was unthinkable just a few years ago has been virtually achieved with fewer than 200 new cases of infant HIV infection reported in 1999. Nevertheless, critical research questions as well as public health challenges remain. New infant HIV infections continue to occur among women who did not obtain prenatal care or who were not offered HIV testing during pregnancy and innovative approaches are needed to address these barriers. The CDC-funded Mother-Infant Rapid Intervention At Delivery (MIRIAD) Study in five US metropolitan areas is one such approach that will test the feasibility of offering rapid testing to women presenting late in pregnancy or at delivery with undocumented HIV status. In addition, further research addressing the role of the placenta in preventing or enhancing in utero HIV transmission is needed. Internationally, new clinical trial findings provide hope that a short course of antiretrovirals can substantially reduce vertical HIV-1 transmission in resource-poor settings in the developing world where most paediatric HIV infections occur. Future research will focus on the role of post-perinatal exposure prophylaxis with antiretrovirals administered to the infant and on the prevention of postnatal transmission of HIV-1 through breast milk while maintaining adequate nutrition. A major challenge is to translate trial results into a coordinated public health implementation plan in order to maximally reduce mother-to-child HIV-1 transmission worldwide.

Adult↗

PubMed2002

Ethical issues in the long-term management of progressive degenerative neuromuscular diseases.

Degenerative neuromuscular diseases are characterized by a gradual decline of motor function leading to respiratory collapse, while the patients retain consciousness and cognition. The ethical challenges of caring for such patients result from the need to implement various combinations of initiating, withholding, and withdrawing life-sustaining interventions. In caring for this population of patients physicians should adhere to the ethical principles of autonomy, beneficence, nonmaleficence, and justice. A central goal of care is to avoid a decisional impasse by anticipating end-of-life issues in discussion with patients and families. The evolution of these diseases is usually slow enough to allow ample patient education, and thus physicians should foster early and frank discussions and encourage the patient to set up advance directives, designate a durable power of attorney for health care, and plan end-of-life care. Competent patients have the right to accept or refuse life-sustaining therapies, and such requests should be honored. In delivering palliative care, adequate sedation and analgesia must be provided when needed. If a decision to withhold or withdraw life support is made, patient comfort and dignity are the ultimate objectives.

Journal Article↗

PubMed1999

Ergonomics oriented to processes becomes a tool for continuous improvement.

A holistic view is essential for quality initiatives such as Total Quality Management (TQM), Standard No. ISO 9001:1994 (International Organization for Standardization [ISO], 1994), Concurrent Engineering, Business Reengineering, and Business Process Improvement. The challenge is knowing how to transition from this theoretical concept to implementation. The relationship between quality interest and an ergonomics program will be the focus of this discussion. An ergonomics oriented improvement program includes (a) ergonomics or fitting the job to the person; (b) integration of operations management, safety engineering, medical management, and employees as co-owners of the process; (c) the emphasis of ergonomic precepts in the engineering of new processes and improvement of current processes; and (d) the emphasis of employees taking responsibility for their own well being and the improvement of their work environment. The parallel between the continuous improvement process delineated by the quality-system requirements in Standard No. ISO 9001:1994 (ISO, 1994) and the improvement contributions of ergonomics are very revealing (Getty, Abbott, & Getty, 1995). It is the contention of this approach that if the precepts of ergonomics were applied to the work environment, it would support the objective of world class quality and productivity, resulting in improved global competitiveness of businesses.

Cost Savings↗

PubMedDate not supplied

Transforming an EPA QA/R-2 quality management plan into an ISO 9002 quality management system.

The Environmental Protection Agency's (EPA) Office of Emergency and Remedial Response (OERR) requires environmental data of known quality to support Superfund hazardous waste site projects. The Quality Assurance Technical Support (QATS) Program is operated by Shaw Environmental and Infrastructure, Inc. to provide EPA's Analytical Operations Center (AOC) with performance evaluation samples, reference materials, on-site laboratory auditing capabilities, data audits (including electronic media data audits), methods development, and other support services. The new QATS contract awarded in November 2000 required that the QATS Program become ISO 9000 certified. In a first for an EPA contractor, the QATS staff and management successfully transformed EPA's QA/R-2 type Quality Management Plan into a Quality Management System (QMS) that complies with the requirements of the internationally recognized ISO 9002 standard and achieved certification in the United States, Canada, and throughout Europe. The presentation describes how quality system elements of ISO 9002 were implemented on an already existing quality system. The psychological and organizational challenges of the culture change in QATS' day-to-day operations will be discussed for the benefit of other ISO 9000 aspirants.

Environmental Monitoring↗

PubMed2004

Tuberculosis prevention and control in long-term-care facilities for older adults.

In the United States, older adults comprise 22% of cases of tuberculous disease but only 12% of the population. Most cases of tuberculosis (TB) occur in community dwellers, but attack rates are highest among frail residents of long-term-care facilities. The detection and treatment of latent TB infection and TB disease can pose special challenges in older adults. Rapid recognition of possible disease, diagnosis, and implementation of airborne precautions are essential to prevent spread. It is the intent of this evidence-based guideline to assist healthcare providers in the prevention and control of TB, specifically in skilled nursing facilities for the elderly.

Aged↗

PubMed2026

Managing workflow executions with WESkit.

SUMMARY: In biomedical research, managing computational workflows across numerous projects-with varying parameters, tools, and environments-creates major challenges in scalability, reproducibility, and collaboration. Here, we present WESkit, an implementation of the Global Alliance for Genomics and Health (GA4GH) Workflow Execution Service (WES) interface, designed to streamline the execution, monitoring, and documentation of data processing workflows. It addresses the complexities involved in managing numerous executions with varying parameters across diverse research projects. Supporting both Snakemake and Nextflow, the system enables consistent automation and centralized monitoring, which benefits research groups aiming for long-term reproducibility and scalable collaboration. Its suitability for larger teams and service units is further enhanced by seamless integration into cloud environments, contributing to the GA4GH cloud framework. AVAILABILITY AND IMPLEMENTATION: The software WESkit is available under MIT license at the GitLab repository (https://gitlab.com/one-touch-pipeline/weskit). The WESkit main repository is archived at Software Heritage (https://archive.softwareheritage.org/browse/origin/directory/?origin_url=https://gitlab.com/one-touch-pipeline/weskit/api.git) and can be found using "one-touch-pipeline/weskit" term in the search section.

Workflow↗

PubMed2002

Assessment of specialist registrars in rheumatology: experience of an objective structured clinical examination (OSCE).

OBJECTIVES: Assessment of higher medical trainees (specialist registrars) in rheumatology is an important challenge facing the rheumatology community, particularly with the advent of the implemention of the changes recommended by the Calman Report in the UK. So far there has been remarkably little work in this area. Our aim was to implement and evaluate an objective structured clinical examination (OSCE) for rheumatology specialist registrars (SpRs). METHODS: Twelve SpRs completed a 12-station OSCE designed to assess core rheumatological clinical skills. The OSCE was designed and manned by consultant members of the West Midlands Rheumatology Services and Training Committee. The OSCE was evaluated by the SpRs, the participating consultant supervisors and the patients, by means of questionnaires. RESULTS: We present the details of the OSCE stations and the scores for each station. In terms of evaluation, 11 out of 12 SpRs felt that it was a very worthwhile exercise. Participating patients found it interesting, if tiring. All would be happy to participate in such an examination again. All participating consultants found it interesting and useful in terms of establishing the level of competence among trainees. CONCLUSION: The OSCE represents one practical approach to assessing clinical skills in rheumatology SpRs. It has potential in both formative and summative assessment. The broader issues around the assessment of rheumatology trainees are discussed.

Clinical Competence↗

PubMed1998

Integrating the teaching of basic sciences, clinical sciences, and biopsychosocial issues.

In this chapter, the author describes integrating the teaching of the basic sciences, clinical sciences, and biopsychosocial issues in medical education as part of the curricular reform efforts initiated by schools that participated in The Robert Wood Johnson Foundation's project "Preparing: Physicians for the Future: Program in Medical Education." The author focuses on the approaches the eight schools adopted, the challenges they encountered, and the lessons they learned in attempting to implement more integrated curricula. Integration was promoted both within and among various components of medical education. For example, in some cases discipline-based courses in the basic sciences were replaced with interdisciplinary courses. Further, efforts were made both to bring clinical relevance to the basic sciences and to strengthen basic science in the clinical years. All the schools also promoted the study of the humanities and biopsychosocial sciences throughout the curriculum. The author describes problems encountered in these endeavors, resources needed to support interdisciplinary courses, the benefits of integration, and common lessons learned by the eight schools.

Biology↗

PubMed2002

A women's health track for internal medicine residents using evidence-based medicine.

OBJECTIVES: Evidenced-based medicine has established itself as an integral part of medical education and practice. The explosion of new knowledge in women's health and the need to teach this to internal medicine residents in an evidence-based fashion have presented a challenge to medical educators. To address this need, we developed and implemented an evidence-based women's health curriculum to be used in addition to clinical training in a women's health center for internal medicine residents. The objectives of the curriculum are to (1) define and utilize basic evidence-based medicine concepts to critically analyze women's health literature, (2) understand recent innovations in women's health from an evidence-based viewpoint, (3) gain clinical experience in women's health, and (4) apply evidence-based medicine to the clinical practice of women's health. DESCRIPTION: We designed our curriculum based on recommendations from the National Academy of Women's Health Medical Education, the American Board of Internal Medicine, the Fifth Report of the Council on Graduate Medical Education, and the results of needs assessments of internal medicine residents at our institution. Using Medline to create a women's health bibliography, an extensive literature search was performed on the following topics: osteoporosis, breast cancer, hormone replacement therapy, domestic violence, coronary artery disease in women, menopause, headaches, substance abuse in women, urinary incontinence, dementia, sexual dysfunction, and evidence-based medicine. Peer-reviewed journal articles were compiled by subject matter for placement in our clinic's resource center and were entered into a computerized database that will link with online journals and be available for electronic access. Most articles were selected based on the criteria of data published since 1990, and randomized, double-blinded, placebo-controlled studies were given preference. Weekly 45-minute sessions preceding the resident clinic in the women's health center are held in a journal-club format to review literature in a systematic fashion. Faculty and residents review and analyze one to two articles weekly. Content experts provide context and clinical expertise to resident discussions. Clinical questions, such as "Should I prescribe hormone replacement therapy to my postmenopausal patient?" are addressed in each session. Evidence-based medicine core concepts are reviewed and applied; these core concepts include the number needed to treat, absolute risk reduction, and relative risk. DISCUSSION: The women's health curriculum, weekly conferences, and clinical experience serve to update residents and clinicians in women's health literature, to exchange ideas for the improvement of women's health as it is taught in internal medicine, and to further elucidate the evidence behind what we practice and teach. The curriculum equips physicians to provide patients with solid, evidence-based interpretations of new scientific knowledge to discern truth from fallacy.

Curriculum↗

PubMed1993

An intrapreneurial approach to foot care.

Continual maintenance of an intrapreneurial foot care clinic has proven to be challenging and financially rewarding for two gerontological CNSs who designed and implemented the clinic. The foot care clinic has been in operation for over three years, and is now considered a part of the routine health services offered to patients in a large, university-based, ambulatory care clinic.

Aged↗