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It has been shown that 65.8% of 343 women died in the second trimester and 69.6% after an illegal abortion. Sepsis and peritonitis were the main causes in the general population (73.9%) and in women who died from illegal abortions (88.6%). Defects in medical care were found.
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In order to realize a good health policy that, over the long term, combines humanity, effectiveness and efficiency, corrections in the evolution of the number of physicians, changes in the structure of practices, and the preservation of quality in ambulatory care are urgent tasks for the remaining decade of this century. In this connection, the development of medical orientational data and the so-called priority health aims, will be of use. In particular, the system of "health-insurance" doctors is threatened by external influences outside the control and authority of the administrative organs concerned. Here, the influence on the overcapacity of doctors arises in the present constitutional provision which states that all those physicians who wish to work within the health-insurance system, must be allowed to do so. Owing to the increasing "financial bottlenecks" that health-insurance doctors will encounter, the future practicing physician will increasingly become a "businessman", since rising costs and decreasing turnover will exercise a powerful effect on the doctor's practice. In such a situation new practice structures might have a positive effect. In view of all these factors that threaten the independence of the practicing physician, the difficulty arises of preserving the quality of medical care. Already, attempts are being made, on an "outside the medical profession" basis, to ensure quality control, and the proposals made by the expert councils are an indication that this discussion must be intensified among the medical profession itself.
BACKGROUND: Patients who undergo surgery for colorectal cancer resulting in an abdominal stoma need extensive teaching and counseling to fully recover and enjoy a satisfactory quality of life. METHODS: The economics of health care, changes in length of hospital stay, what and how patients are taught, and ways in which adults learn were reviewed. Each of these influences on acquisition of self-care skills and knowledge were considered as they apply to the specific needs of stoma patients. RESULTS: Common misconceptions about ostomies should be dispelled to clear the way for adults to learn what they need to know to care for their ostomy. Postoperative teaching must wait until patients are alert and comfortable enough to attend to instruction. Educational material should be prepared at the patient's level of understanding. CONCLUSIONS: An adequate budget for education and dedicated patient education personnel are necessary for effective perioperative teaching and counseling of ostomy patients. In today's health-care system, patients who require a stoma need access to outpatient preoperative and postoperative training and emotional support.
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Practice guidelines are standardized specifications for managing particular clinical problems and are intended to improve the outcomes of medical care by increasing adherence to standards of care. They are also meant to make medicine more cost-effective by eliminating unnecessary procedures. A relatively recent phenomenon, the practice guidelines now emerging will have implications for malpractice, which also intends to bring about better care. They will probably not revolutionize the procedures that courts use to determine negligence, but judges will integrate guidelines into their decision-making process. This development should be welcomed. Guidelines should prove to be useful as either inculpatory or exculpatory evidence of negligence. They are unlikely to generate much new litigation, although there is some potential for suits against those who issue guidelines, especially if guidelines are not revised as the technology of medical care changes.
OBJECTIVE: To pilot a method of assessing psychological care by general practitioners. DESIGN: Prospective examination of psychological care given in general practice by using general health questionnaire with predetermined quantifiable and case specific indices of outcome established at the original consultation. SETTING: Rural general practice in Clwyd, North Wales. SUBJECTS: 447 consecutive adult general practice attenders. MAIN OUTCOME MEASURES: Three month follow up consultation rates, one year retrospective consultation rates, continuity of care, changes in general health questionnaire scores at follow up, general satisfaction, and acceptability of outcome measures. RESULTS: The principal and trainee identified 72 patients with psychological problems, 46 of whom had new conditions. 133 patients scored over 6 on the 28 item general health questionnaire, 33 of whom were identified as new cases by the general practitioners. 62 patients were seen at follow up, including 23 patients identified by the questionnaire but not by the doctor. The doctors used diagnostic terms to describe the presenting condition in 38 cases. At three month follow up the general health questionnaire scores had fallen by more than 5 points in 22/39 patients identified and managed by doctors and 11/23 identified by the questionnaire. The agreed index of good outcome was almost or completely achieved by 20 of the 39 patients managed by doctors. CONCLUSION: Quantifiable methods of evaluating the quality of the structure, process, and outcome of psychological care can be achieved in general practice.
The University of Washington Health of the Public Program has convened a consortium composed of the region's academic medical center, the two largest managed care plans in Washington, and representatives of the state's major private and public purchasers of health care. The consortium's purpose is to test the feasibility of collaboratively collecting cross-system data, assessing variations in practice, and implementing site-specific interventions to improve the management of common illnesses and encourage preventive care. Changes under way in the ambulatory training environment and in the undergraduate curriculum as a result of the consortium's initial efforts are described. In today's climate of cost consciousness and concerns about quality, academic medical centers can play an important role in helping to improve community-wide outcomes of care.
Changing complementary goals in medicine, nursing and care pose new challenges to health professionals. The needs of the incurably ill or dying individuals and their relations are acknowledged more intensively again today. Quality of life and comprehensive care are corner-stones in the treatment and care of this group of patients. Realisation of the principles of palliative medicine and care demands a targeted approach to this multifaceted and burdening field. Nurses, doctors, social workers and other therapists have not yet been optimally prepared for this task. A common interdisciplinary training in this evolving field gives all the specialists from the different fields an opportunity for preparation to this task.
Changes within the health care system necessitate changes in nursing practice. Given the financial environment and the need to balance the cost/quality equation, case management will become increasingly important and has the potential to become the predominant care delivery system of the 1990s. This transition represents a tremendous opportunity for nursing. The CCM role offers many potential advantages and benefits for individual nurses and the profession as a whole. Nurses practicing as case managers have the opportunity to function in a highly professional, independent manner with a great deal of interdisciplinary collaboration. In addition to the challenges and satisfactions of the work itself, the nurse case manager may also enjoy a higher salary and more scheduling control and flexibility. The broader advantages of case management include its benefits to patients and institutions and its fit with current trends in the health care environment. Nurse case managers manage hospital systems to produce optimal clinical outcomes for patients in the shortest time using as few resources as possible. This approach to care delivery places nurses in a position to demonstrate the tremendous contribution they can make to achieving the institution's goal of delivering high-quality, cost-effective care. Thus, case management fits extremely well with current trends in health care financing and outcome measurement. The model described in this article illustrates one approach to implementing these important concepts in a critical care setting.
So where does all of this lead us? Many QA professionals are currently concerned that CQI will displace their role. Nurses are concerned that they will have to learn an entirely new process and language. In a National Association of Quality Assurance Professionals position paper, Martin (1990) points out that CQI builds on and strengthens the weaknesses of traditional quality assurance approaches. Quality improvement is not a substitute for quality assurance; it is a supplement to expand health care providers' understanding of the components of excellent patient care. Change and variation surrounds us at all times. Continuous quality improvement teaches the premises of variation and change. Through a better understanding of variation and application of this understanding to continuous improvement of the system of care, we will help assure better outcomes for our clients. Nurse administrators and staff nurses should endorse the arrival of continuous quality improvement. As leaders in QA, we are indeed positioned to become leaders in CQI.
In Costa Rica, three sequential health paradigms have been identified over the last 50 years. The first began to develop during the 40's and has been called that of the deficiency diseases, since with a diachronic approach it placed excessive emphasis on malnutrition. The second began in 1970 and it is known as that of the infectious diseases, since through a holistic or synchronic approach, it underlined the importance of infections in high rates of morbidity and mortality. The third and last is the paradigm of the chronic diseases, it appeared in the 80's and is presently in process, doing battle with the chronic ailments, life styles, and environment, and it also utilizes a holistic approach. The recognition of these three paradigms has permitted Costa Rica a rapid advance in improving the health of its population, to the point that with a per capita outlay of $130 (US dollars), it has indices similar to those of the industrialized nations. This particular experience could be useful for other less-developed countries that are still applying the paradigm of the deficiency diseases.
Due to historical developments emphasis in thinking and acting in dentistry was placed on providing care. Changes in society and dentistry resulted in a greater patients' independence and in an increased demand for service. Marketing enables to cope with the transformation of care into service and improves efficiency and quality.
As a result of the restrictive reproductive health policies enforced under the 25-year Ceausescu dictatorship, Romania ended the 1980s with the highest recorded maternal mortality of any country in Europe--159 deaths per 100,000 live births in 1989. An estimated 87 percent of these maternal deaths were caused by illegal and unsafe abortion. Under the Ceausescu regime, all contraceptive methods were forbidden and induced abortion was available only for women who met extremely narrow criteria. Immediately after the December 1989 revolution that overthrew Ceausescu, the new government removed restrictions on contraceptive use and legalized abortion. This legislative change has had beneficial effects on women's health, seen in the drop in maternal mortality in 1990 to 83 deaths per 100,000 live births--almost half the ratio in 1989. In addition, changes instituted since the revolution have led to the improved availability of reproductive health services and to the creation of new educational and training opportunities related to reproductive health services and to the creation of new educational and training opportunities related to reproductive health. The newly created contraceptive and abortion services have presented health system managers and policymakers with many challenges as they work to expand the availability of high-quality, comprehensive reproductive health care in a setting of economic hardship, political unrest, insufficient infrastructure, and outdated medical knowledge and practice.
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Concern for quality, cost, and access dominate the health care system in the eighties. State and national actions, demographic changes, and technological advances are converging to create many changes in the home care delivery system. Knowledgeable nurses can influence the evolution of home care services to assure that patients receive appropriate acute and long term home care services. Concern for quality care, changing patient needs, and availability of care are the major issues facing home care nursing in the eighties, and will continue to be into the nineties. Reimbursement policies of third party payers, medicare/medicaid regulations, state licensing, employer benefit programs, state health programs, home health care providers, professional/trade associations, and consumer advocacy groups are some of the key forces reshaping the practice of home health nurses. Knowledge of these factors will enable nurses to influence effectively the design of institutional and governmental policies which affect the care nurses deliver to patients at home.