CCCM guidelines on confidentiality.
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Confidentiality↗
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The progress of lay involvement in the NHS Research and Development Programme.
The Central Research and Development Committee is seeking to involve lay perspectives in the NHS R&D Programme. This paper describes some recent examples of lay involvement in each step of the research process from setting the agenda to making use of research findings. Innovative approaches have involved lay people in identifying research need and in the subsequent commissioning process. Lay contributions have given particular emphasis to information and support, whether this is in maternity care, cancer care, HIV prevention, participation in clinical trials or systematically reviewing evidence of effectiveness. Difficulties in identifying appropriate lay people to involve in research, their different skills, their lack of resources and support and their need for time for thought and discussion with their peers have all posed problems. Suggestions for overcoming some of these obstacles are presented, including resources, training and support, and clarification of the role, nature and potential for lay involvement. Lastly this paper considers the urgent need to learn from the efforts made so far, possible approaches to evaluation and how this is being addressed by a newly convened advisory group to the Central R&D Committee.
Community Participation↗
The evolving horizon of drug registration--Europe and beyond.
The thalidomide tragedy gave rise to national drug regulation without thought to international harmonization. Thus from the early days of the European Community (EC), there has been a barrier to the free movement of medicinal products. Previous attempts have failed to resolve the problem and the European Commission is currently involved in attempting to establish Community drug legislation which will remove these barriers and create a single internal market. The Commission advocates two procedures (a centralized and a decentralized) largely under the control of the Committee for Proprietary Medicinal Products (CPMP) within the framework of a new European Agency for the Evaluation of Medicinal Products. The present authority of the Commission to make decisions binding on all 12 Member States will be utilized by the CPMP. While the present draft legislation should create significant improvement towards the goal of a single market, it contains some areas of potential concern. That this major venture should be a success is not only critical to the EC economy, its research-based pharmaceutical industry and the health care of its citizens but also to the achievement of global harmonization for pharmaceutical marketing authorization for which there is much evidence of enthusiasm and desire.
European Union↗
A new rating form for use by nurses in assessing residents' humanistic behavior.
OBJECTIVE: To determine the reliability and validity of an evaluation form for assessing the humanistic behavior of internal medicine (IM) housestaff. The form is for use by nurses. DESIGN: Evaluations were gathered three times during the 1987-88 academic year. Generalizability coefficients (interpreted like traditional reliability coefficients) were generated to establish the form's reliability, while data from attending physicians and from housestaff evaluation committee members were used to help establish its validity. SETTING: Three hospitals in central Ohio: a large university tertiary care center, a large private hospital, and an urban community hospital. PARTICIPANTS: The nurse raters were volunteers solicited by their head nurses. The criteria governing their participation were two years of postgraduate experience in nursing and regular contact with residents, which was self-determined. All IM residents who had worked on a medicine inpatient service at least once during the months under study were included. A total of 493 nurses and 116 residents participated. RESULTS: Sixty-four percent of the generalizability coefficients were 0.90 or higher, and 82% were above 0.75, indicating stable, reliable ratings. The nurses' ratings were positively and significantly correlated with attending faculty's and evaluation committee members' ratings (r = 0.38, p less than 0.01; r = 0.49, p less than 0.001). CONCLUSIONS: The evaluation form and the nurses provided consistent, reliable information about medical residents' humanistic behavior; data from five to six nurses should provide statistically reliable ratings using this form. Also, nurses' data yielded information somewhat different from those provided by physicians, suggesting that the form is a useful instrument for assessing this dimension of residents' performance.
Adult↗
Characteristics and functions of community health workers in Saradidi, Kenya.
A community-based health development programme in Saradidi, Kenya had 126 village health helpers (VHH's) for the 56 villages. These volunteer health workers lived in the community and served a total population of about 43,000 in an area of 225 km2. Each VHH served a maximum of 100 households averaging 4.0 persons. Conditions imposed by the community were that the VHH be perceived to be a mature person, to be compassionate and to have a desire to help people and to live in the village. Literacy or formal education were not requirements. VHH's were chosen and supported by the people who lived in their village. Characteristics of the 126 VHH's were that 96.8% were women, 99.2% were married, 75.4% were between 25 and 39 years of age, and 80.2% had at least five years of formal education (only 7.1% had none). The VHH's spent an average five to ten days each month on programme activities in addition to their other responsibilities which included preparing meals, cleaning their homes, carrying water and firewood from long distances, caring for their children and cultivating food for their family. Each VHH visited about 15 households per month, spending one to two hours on a visit. Problems experienced by a random sample of 36 VHH's included difficulties due to lack of transport, lack of medicines, slowness of the community to accept new ideas, distance from project clinic, lack of food in the village, weak village health committees, and no payment for services. The main support for the VHH's came from village women individually, women's groups, and the central programme committee. Village Health Committees did not provide effective support. Nevertheless, in four years only four of the 126 VHH's dropped out of the programme. The main reasons that 36 VHH's reported for continuing to volunteer were as follows: the continuous training they were given was beneficial (mentioned by all); they agreed to serve the villages and did not want to go back on their word (36.1%); they liked the work (19.4%); they felt they have an impact on the health of people in the village (16.7%); the allowances they sometimes receive (22.2%); and personal development (13.9%). The characteristics and responsibilities of community health workers in Saradidi were similar to those elsewhere. The ingredients for a successful volunteer programme such as this one are present in many areas.(ABSTRACT TRUNCATED AT 400 WORDS)
Activities of Daily Living↗
[An integrated program of occupational medicine: a proposal for medical schools in Brazil].
The article is animated essentially by a conviction of the feasibility and necessity of acting to improve the health of workers by making the most of the opportunities and instruments offered by the medical sciences. Following an account of the present status of occupational health/occupational medicine in Brazil, a description is given of the areas in which action could be taken in these fields in Brazil today, and the priorities in the areas of instruction, research and community services are identified, which are the proper province of the medical schools. The article then states the characteristics and policies of a Comprehensive Occupational Medicine Program as a practical alternative for new programs. This program should not necessarily become a new discipline or department in the medical school, but be conceived, implemented and administered as a system, that is, as an inter- or multidisciplinary network, and should hence have an advisory committee representing the departments in the school that participate in the program. To facilitate the establishment of this network, the article proposes setting up a central unit for the program and enumerates the functions it should have. Finally, a number of strategies for implementation of the program are proposed and some activities identified that could be set in motion in the short term.
Brazil↗
Community genetics and dignity in diversity in the Quebec Network of Genetic Medicine.
The Quebec Network of Genetic Medicine (QNGM), implemented in 1971, has been an integrated program of community genetics serving the population (approximately 7.5 million) of Quebec province in Canada. QNGM reported to the Minister of Social Affairs and operated under an umbrella of universal health insurance in the province. The Network's programs have been run by members of the four university medical schools of the province under the direction of a central committee. A global annual budget was awarded to QNGM from its inception. Among its many programs, QNGM supported: (1) two newborn screening programs (using blood and urine samples) for early diagnosis, treatment and research in phenylketonuria, hereditary tyrosinemia, congenital hypothyroidism, and in a large number of other hereditary metabolic diseases; (2) follow-up of confirmatory diagnostic tests at regional centers, followed by supervision of ambulatory treatment modalities; (3) carrier screening and reproductive counseling for Tay-Sachs and beta-thalassemia diseases; (4) a spectrum of feasibility (research) studies (e.g., screening for biotinidase deficiency, neuroblastoma, hemoglobinopathies, and cystic fibrosis) to inform policy decisions. QNGM performed economic analyses of its major programs and followed prevailing ethical guidelines. Its global budget and integrated structure terminated in 1994, although some of its programs continue independently.
Cystic Fibrosis↗
Voices from family medicine: Thomas Leaman. Interview by William B. Ventres and John J. Frey.
Thomas Leaman's relationship with the community of Hershey, Pa., extends over a period of 42 years. He began his commitment to that small central Pennsylvania community as one of its doctors; later he served as the first chair of the Department of Community and Family Medicine at the Pennsylvania State University School of Medicine in Hershey. He chaired the department from 1967 to 1987 and has been professor emeritus since that time. Dr. Leaman was president of the Society of Teachers of Family Medicine in 1982 and has continued to have an active role in many aspects of the Society, including the Long Range Planning and Medical Records Committees. He also served as a founding member of the Association of Departments of Family Medicine. This article is edited from interviews that occurred in May 1991 and July 1992.
Family Practice↗
Corporate nuclear medicine: the implementation of a centralized management model.
OBJECTIVE: A trend in corporate healthcare is the merging of small community hospitals with larger regional hospitals to expand the patient base. The purpose of this article is to illustrate the benefits of operating several nuclear medicine departments under a centralized management system, rather than operating many decentralized departments. The issues discussed are the development, financial benefits, operations, and structure of a corporate nuclear medicine department. METHODS: Seven nuclear medicine departments were integrated to form one corporate nuclear medicine department from a large hospital organization comprising seven different hospitals. The management team created the concept and advised administration. Training programs were designed and implemented, and committees were formed to ensure the efficient operation of the integrated department. All aspects of the department, such as scheduling and interpretation of studies, are managed at a central location. All technologists rotate to all hospitals. Success was measured by cost savings, study turn-around times, and evaluation of patient and employee satisfaction. RESULTS: It was found that establishing a corporate nuclear medicine department created a greater patient base by servicing a larger geographic area, and resulted in savings of $870,000 annually. Standardizing procedures and protocols allowed for consistency in patient care, an inpatient turnaround time of 24 h, and a dictated report turnaround time of 30 min. Employee relations and satisfaction remained consistent with a 4.76 out of a 5.0 leadership index rating. CONCLUSION: A nuclear medicine department with a centralized management system is a viable option for corporate health care. It is recommended for operations endeavoring to expand the patient base and improve the financial picture.
Centralized Hospital Services↗
Education for primary health care.
Postrevolutionary Nicaragua has developed a new health system in which primary health care is a central component. Great progress has been made in correcting the poor health conditions that existed prior to the revolution. As part of an interdisciplinary health team that emphasizes prevention and community service, physicians in the new system play a different role than they did previously. Training for health workers of all types has been expanded. However, scarce teaching and curricular resources have restrained progress in this area. The U.S. based Committee for Health Rights in Central America (CHRICA) has collaborated with the Nicaraguan Ministry of Health to organize two Colloquia on Health in Nicaragua in the past two years. These Colloquia brought together North American participants who provided current medical training and Nicaraguan participants who provided information about the new health system. The Colloquia, whose participants were eligible to receive CME credit from the UCSF School of Medicine, have led to continuing educational exchanges between health care personnel in the two countries.
Education, Medical↗
Toward an integrated resource for pharmacogenomics (PGx): Survey findings from the genomic medicine communities.
PURPOSE: Pharmacogenomics (PGx) is a critical component of precision health care that aims to improve drug efficacy and reduce adverse events. Terminologies and standards have not always aligned between PGx and broader genomic medicine communities, which is a barrier to PGx implementation. An updated assessment of community barriers, needs, and perspectives is critical to enable more standardized terminologies and interpretation frameworks. METHODS: The Clinical Genome Resource's PGx Interpretation Committee (PGxIC, formerly referred to as the PGx Working Group, PGxWG) conducted 2 surveys targeting the PGx and genomic medicine communities (n = 508) to evaluate perspectives on PGx clinical validity and actionability frameworks, as well as other barriers to PGx implementation. Surveys were tailored toward self-reported familiarity with PGx. Data primarily consisted of free text, which were analyzed using qualitative content analysis methods. RESULTS: Survey responses indicated conflation of terminology across disciplines, including confusion around differing definitions of terms in PGx and non-PGx contexts. Data also indicated broad support for leveraging existing PGx guidelines and framework structures alongside the standardization of approaches and centralization of resources. CONCLUSION: These novel survey results demonstrate broad consensus on the importance of integrating PGx into clinical practice, including support for development of gene-drug response clinical validity and actionability frameworks aligned with Clinical Genome Resource's frameworks for gene-disease relationships.
Humans↗
Developing a "clinical presentation" curriculum at the University of Calgary.
Currently, medical curricula are structured according to disciplines, body systems, or clinical problems. Beginning in 1988, the faculty of the University of Calgary Faculty of Medicine (U of C) carefully evaluated the advantages and disadvantages of each of these models in seeking to revise their school's curriculum. However, all three models fell short of a curricular structure based on current knowledge and principles of adult learning, clinical problem solving, community demands, and curriculum management. By 1991, the U of C had formulated a strategic plan for a revised curriculum structure based on the way patients present to physicians, and implementation of this plan has begun. In creating the new curriculum, 120 clinical presentations (e.g., "loss of consciousness/syncope") were defined and each was assigned to an individual or small group of faculty for development based on faculty expertise and interest. Terminal objectives (i.e., "what to do") were defined for each presentation to describe the appropriate clinical behaviors of a graduating physician. Experts developed schemes that outlined how they differentiated one cause (i.e., disease category) from another. The underlying enabling objectives (i.e., knowledge, skills, and attitudes) for reaching the terminal objectives for each clinical presentation were assigned as departmental responsibilities. A new administrative structure evolved in which there is a partnership between a centralized multidisciplinary curriculum committee and the departments. This new competency-based, clinical presentation curriculum is expected to significantly enhance students' development of clinical problem-solving skills and affirms the premise that prudent, continuous updating is essential for improving the quality of medical education.
Alberta↗
Joint working, reality or rhetoric?
The UK Government has put the elimination of health inequalities and social exclusion at the heart of its agenda. Partnership working is clearly needed to tackle these issues and has been identified as the way forward in a series of policy initiatives. This paper explores whether, despite the rhetoric, joint working happens in reality. Using the example of the Social Exclusion Unit, a 'cross-cutting' unit developed to work across organizational boundaries, it suggests that centrally joint working is not working effectively. As a result, public health programmes are not being well co-ordinated with wider government initiatives and public health appears to be excluded from much of the work around social exclusion. Two potential reasons are identified: (1) poor co-ordination between the Department of Health and the Cabinet Office; (2) a lack of understanding in the wider community of public health and the role it can play in tackling inequalities and social exclusion. A House of Commons Health Committee is currently examining co-ordination between central government, local government and health authorities in delivering public health. Meanwhile, the public health community must attempt to clarify and, if necessary, market its role and strengths in this sphere. Unless directives from central government are better co-ordinated, local efforts to work in partnership could be undermined.
Community Health Planning↗
Improving health care globally: a critical review of the necessity of family medicine research and recommendations to build research capacity.
An invitational conference led by the World Organization of Family Doctors (Wonca) involving selected delegates from 34 countries was held in Kingston, Ontario, Canada, March 8 to 12, 2003. The conference theme was "Improving Health Globally: The Necessity of Family Medicine Research." Guiding conference discussions was the value that to improve health care worldwide, strong, evidence-based primary care is indispensable. Eight papers reviewed before the meeting formed the basic material from which the conference developed 9 recommendations. Wonca, as an international body of family medicine, was regarded as particularly suited to pursue these conference recommendations: 1. Research achievements in family medicine should be displayed to policy makers, health (insurance) authorities, and academic leaders in a systematic way. 2. In all countries, sentinel practice systems should be developed to provide surveillance reports on illness and diseases that have the greatest impact on the population's health and wellness in the community. 3. A clearinghouse should be organized to provide a central repository of knowledge about family medicine research expertise, training, and mentoring.4. National research institutes and university departments of family medicine with a research mission should be developed. 5. Practice-based research networks should be developed around the world.6. Family medicine research journals, conferences, and Web sites should be strengthened to disseminate research findings internationally, and their use coordinated. Improved representation of family medicine research journals in databases, such as Index Medicus, should be pursued.7. Funding of international collaborative research in family medicine should be facilitated.8. International ethical guidelines, with an international ethical review process, should be developed in particular for participatory (action) research, where researchers work in partnership with communities. 9. When implementing these recommendations, the specific needs and implications for developing countries should be addressed.The Wonca executive committee has reviewed these recommendations and the supporting rationale for each. They plan to follow the recommendations, but to do so will require the support and cooperation of many individuals, organizations, and national governments around the world.
Biomedical Research↗
The Ontario Cancer Treatment Practice Guidelines Initiative.
The Ontario Cancer Treatment Practice Guidelines Initiative was established in 1993 to develop clinical practice guidelines for cancer treatment in Ontario, Canada. First, an organizational structure, consisting of a coordinating committee, a methods resource group, and disease site groups, was put in place. Central to the development of guidelines are the 10 provincial site groups, which use a methodologic framework, the practice guidelines development cycle, to formulate the guidelines. When a preliminary evidence-based recommendation is developed by a site group, it is sent out to a sample of community practitioners for input and is modified based on their feedback. The final product is the practice guideline. Further research is required to determine optimal dissemination strategies and evaluate the impact of these guidelines.
Evidence-Based Medicine↗
Regulation and abuse liability testing of medicines in Europe beyond 1992.
The procedures for approving medicines have been progressively harmonized within the European Community. The authorization of medicinal products beyond 1992 will be based on a more centralized procedure, with important safeguards to ensure that there is no dilution of strict standards of quality, safety, and efficacy. Although some efforts have been attempted to coordinate the procedures for approving medicines with Japan and the United States, some important problems still remain. An example of this lack of coordination is the lack of agreement about applying abuse liability testing to psychotropic drugs. In the United States, abuse liability data are routinely used for scheduling and labeling new drugs under the supervision of the Food and Drug Administration (FDA). This agency has codified the requirements for clinical studies of potential abuse of psychotropic drugs and requires pharmaceutical sponsors to submit specific data. However, requirements within the European Community in this matter are minimal. Clinical trials on subjective effects, drug discrimination or drug preference are not requested. This situation demands more scientific interchange between officials and scientists from the FDA and their counterparts from Europe. The Committee for Proprietary Medicinal Products (CPMP) must play a major role in this coordination and interchange.
Drug Evaluation↗
Managerialism and the British GP: the GP as manager and as managed.
The focus of the paper is on the relationship between General Practitioners (GPs) and central government. This relationship dates from the introduction of national health insurance in the UK. From the outset it had an impact on GPs' medical role, their professional status and income. The structure created in 1911 meant that GPs operated as franchisees and, notwithstanding Labour's policy objective of creating a salaried service, this role continued, effectively unchanged, after the creation of the National Health Service (NHS) in 1948. General practice was also the poor relation in contrast to hospital medicine, a feature intensified by the priorities of the NHS. These forces meant that GPs had a dual role: that of clinician and gatekeeper to specialist hospital services, a role in which they exercised substantial clinical freedom: and running a small business, a feature which was exaggerated by the absence of grant aid to improve premises prior to the Family Doctor Charter of 1965. This structural relationship has been progressively transformed by changes in the 1980s and 1990s. On the one hand the emphasis on cost control has seen central government attempting to combine a financial with a clinical gate-keeping keeping role. The crucial change in this respect is the creation of GP fundholding which, in turn, could be seen to have implications for the subordinate status of GPs within the medical profession. However, this has been combined with trends to greater measures of control over GPs. Of central importance in this respect were the changes introduced by the 1990 GP contract. The contract involved an attempt to substantially reduce clinical autonomy by building in much more detailed contractual duties with respect, for example, to health promotion activities. This was combined with the use of financial incentives to reach, for example, immunization targets. Control over clinical autonomy has also involved constraints over prescribing and the shift from Family Practitioner Committees to Family Health Service Authorities. The rationale for this shift is the move from an administrative to a managerial body, acting as the agent of central government in enforcing the contract and imposing financial norms. GPs are thus to be made managerially accountable. The paper analyses the place of general practitioners in central government's approach to health strategy and examines the tensions generated by the combination of conferring new powers on GPs and increasing controls over them. These tensions are related to current disputes over out-of-hours working and attempts by GPs to redefine a "core of service" approach to their job. The ambiguities of reliance on professionals combined with the desire to exert greater controls is traced in the recent policy statement by the Secretary of State, Primary Care: The Future (1996). The paper thus aims to contribute to the critical discussion of the impact of central government managerialist initiative on key professional groups in the welfare state.
Community Health Planning↗
A 10-year review of the Teaching Hospital-Based National Drug and Toxicology Information Service in Zimbabwe.
The drug and toxicology information service (DaTIS), at the Department of Pharmacy, University of Zimbabwe Medical School, was set up in 1979. The service is mainly delivered to health professionals and to a lesser extent to the community. The DaTIS is designed to help solve complex clinical questions. Most of the requests are made by telephone. Urgent questions may be initially answered by telephone, or a phone call can be returned after in-depth documentation. A complete answer with references may be written and sent to the enquirer. Written non-urgent questions may be sent a few days to a few weeks later. This report is based on a systematic review of records compiled over the period between January 1983 and July 1988. Of the 1,000 requests received and recorded during the period under consideration, approximately 750 (75%) were on drug information and 250 (25%) were on poisoning or toxicological information. The most common causes of poisonings were due to organophosphate pesticides and fertilizers, Elephant's Ear, Amanita Phalloides mushroom, medicines affecting the central nervous system, e.g. tranquilizers, psychotropics, and chemicals, especially those used for hair relaxing. Only the first three causes of poisoning are discussed in detail. Most of the queries relating to poisoning, especially those received during the night, were not recorded. These results confirm the need for an adequate number of qualified and committed manpower to share the work-load in DaTIS as well as in teaching, research and in the continuous health education of the community. The results obtained by DaTIS and a recent survey (14) indicate that Zimbabwe has a big poisoning problem, especially with regard to pesticides and treatments recommended by the traditional healer. Education and information dissemination to health professionals, workers and the general public on the toxic agents concerned are vital and, although steps have been taken in this direction, much still remains to be done. Moreover, the report confirms the importance of the service to health professionals and the community in the country and the SADCC (Southern African Development Conference Committee) region as a whole.
Drug Information Services↗