Showing papers on "Health care published in 1991"

The concepts and principles of equity and health

Abstract: In 1984, the 32 member states of the World Health Organization European Region took a remarkable step forward in agreeing unanimously on 38 targets for a common health policy for the Region. Not only was equity the subject of the first of these targets, but it was also seen as a fundamental theme running right through the policy as a whole. However, equity can mean different things to different people. This article looks at the concepts and principles of equity as understood in the context of the World Health Organization's Health for All policy. After considering the possible causes of the differences in health observed in populations--some of them inevitable and some unnecessary and unfair--the author discusses equity in relation to health care, concentrating on issues of access to care, utilization, and quality. Lastly, seven principles for action are outlined, stemming from these concepts, to be borne in mind when designing or implementing policies, so that greater equity in health and health care can be promoted.

The Computer-Based Patient Record: An Essential Technology for Health Care

Abstract: From the Publisher: In its first edition, this volume presented a blueprint for introducing the computer-based patient record (CPR) nationwide within the next decade. An expert committee explored the potential of machine-readable CPRs to improve diagnostic and care decisions, provide a database for policy-making, and much more. This revised edition adds new information to the original book. One commentary describes recent developments in the United States, including the creation of a computer-based patient record institute - a strategy recommended in the original volume to promote and facilitate implementation of the CPR. The second commentary highlights developments in Europe. The volume also explores such issues as privacy and confidentiality, costs, the need for training, legal barriers to CPRs, and other key topics.

Medicare: a strategy for quality assurance.

Abstract: This paper has outlined a strategy proposed by an IOM study committee for a quality review and assurance program for Medicare. The committee intended that such a program respond to several major issues, including: the burdens of harm of poor quality of care (poor performance of clinicians in both technical and interpersonal ways, unnecessary and inappropriate services, and lack of needed and appropriate services); difficulties and incentives presented by the organization and financing of healthcare; the state of scientific knowledge; the problems of adversarial, punitive, and burdensome external QA activities and the need to foster successful internal, organization-based QA programs; the adequacy of quality review and assurance methods and tools; and the human and financial resources for quality assurance. In comparison with the existing federal peer review organization program, the IOM's proposed program is intended to focus far more directly on quality assurance, cover all major settings of care, emphasize both a wide range of patient outcomes and the process of care, and have a greatly expanded program evaluation component and greater public oversight and accountability. In laying out the details of such a program, the IOM committee advanced 10 recommendations to support its proposed program. Two of these call for the Secretary of DHHS to support and expand research and educational activities designed to improve the nation's knowledge base and capacity for quality assurance. Finally, the committee emphasized both the extraordinary challenges of quality assurance and the diversity of support for addressing those challenges, noting that patients, providers, and societal agents all have a responsibility in this regard. Building the nation's capacity through additional research and expanded educational efforts is a major cornerstone of the entire enterprise.

Prenatal genetic testing and screening: constructing needs and reinforcing inequities.

Abstract: This Article considers the influence and implications of the application of genetic technologies to definitions of disease and to the treatment of illness. The concept of “geneticization” is introduced to emphasize the dominant discourse in today's stories of health and disease and the social construction of biological phenomenon is described. The reassurance, choice and control supposedly provided by prenatal genetic testing and screening are critically examined, and their role in constructing the need for such technology is addressed. Using the stories told about prenatal diagnosis as a focus, the consequences of a genetic perspective for and on women and their health care needs are explored.

The Health Care Quadrilemma: An Essay on Technological Change, Insurance, Quality of Care, and Cost Containment

Abstract: During the roughly four decades since the end of World War II, the health care system in the United States has experienced historically unprecedented change in three dimensions. First, new technologies have revolutionized the ways in which health care is capable of being practiced. Almost all of today's armamentarium of disease diagnosis and treatment devices and techniques were unknown 40 years ago. In the case of prescription drugs, for example, about 10 percent of the 200 largest-selling drugs are new each year; and only 25 percent of the 200 top-selling drugs in 1972 remained in the group 15 years later (David Cleeton, Valy Goepfrich, and Burton Weisbrod 1990).

Patients evaluate their hospital care: a national survey.

Abstract: Respect for patients’ needs and wishes is central to a humane health care system. To better meet patients’ needs, providers have expressed increased interest in using patients’ evaluations and reports to complement other methods of quality assessment and assurance. Many hospitals routinely survey patients, but relatively little analysis of patients’ evaluations of hospital care has been published. Most of the literature on such evaluations is based on studies of outpatients. There have been some excellent descriptions of both the theoretical and practical issues involved in measuring patients’ assessments of inpatient care, but much more work in this area remains to be done. Project goals. The primary goals of the research on which this DataWatch is based were to determine which specific aspects of inpatient care are most important to patients and to document patients’ perceptions of those aspects of care in hospitals nationwide. Another goal was to assess the extent to which variations in reported quality of care might be related to characteristics of patients. In particular, we wanted to investigate whether patients with fewer resources, older patients, or patients in poorer health were more likely to report problems with their care. Here we report the results of a national telephone survey about selected aspects of care. We interviewed 6,455 adult patients recently discharged from the medical and surgical services of sixty-two hospitals selected to represent different hospital types and. all regions of the United States. The interview focused on events that indicate the quality of care in several clinically important areas of which patients are the best judges: patient education and communication with providers, respect for pa-

Delayed access to health care: risk factors, reasons, and consequences.

Abstract: Objective: To determine characteristics of patients reporting delays in care before hospitalization and the reasons for those delays. Design: Survey; personal interviews. Setting: Five hospitals in...

The Health Care Quadrilemma: An Essay on Technological Change, Insurance, Quality of Care, and Cost Containment

Abstract: During the roughly four decades since the end of World War II, the health care system in the United States has experienced historically unprecedented change in three dimensions First, new technologies have revolutionized the ways in which health care is capable of being practiced Almost all of today's armamentarium of disease diagnosis and treatment devices and techniques were unknown 40 years ago In the case of prescription drugs, for example, about 10 percent of the 200 largest-selling drugs are new each year; and only 25 percent of the 200 top-selling drugs in 1972 remained in the group 15 years later (David Cleeton, Valy Goepfrich, and Burton Weisbrod 1990)

Setting health care priorities in Oregon. Cost-effectiveness meets the rule of rescue.

Abstract: The Oregon Health Services Commission recently completed work on its principal charge: creation of a prioritized list of health care services, ranging from the most important to the least important Oregon's draft priority list was criticized because it seemed to favor minor treatments over lifesaving ones This reaction reflects a fundamental and irreconcilable conflict between cost-effectiveness analysis and the powerful human proclivity to rescue endangered life: the "Rule of Rescue" Oregon's final priority list was generated without reference to costs and is, therefore, more intuitively sensible than the initial list However, the utility of the final list is limited by its lack of specificity with regard to conditions and treatments An alternative approach for setting health care priorities would circumvent the Rule of Rescue by carefully defining necessary indications for treatment Such an approach might be applied to Oregon's final list in order to achieve better specificity ( JAMA 1991;265:2218-2225)

Patients Who Leave a Public Hospital Emergency Department Without Being Seen by a Physician

Abstract: OBJECTIVE To determine whether patients who sought care at a public hospital emergency department and left without being seen by a physician needed immediate medical attention and whether they obtained care after leaving. DESIGN Follow-up study of patients who left without being seen and of patients who waited to be seen by a physician. SETTING A public hospital's emergency department in Torrance, Calif. PATIENTS All patients who registered for care and left without being seen (n = 186) and a 20% random sample of patients who waited until they were seen (n = 211) in a 2-week period during spring 1990. MAIN OUTCOME MEASURES At time of presentation: triage nurse urgency assessment, clinical acuity rating, and self-reported health status. At follow-up: hospitalization rates. RESULTS Patients who left reported that they had waited 6.4 hours before leaving; those who stayed reported a 6.2-hour wait before being seen. There were no differences between those who left and those who stayed in chief complaint, triage nurse assessment, acuity ratings, or self-reported health status. Forty-six percent of those who left were judged to need immediate medical attention, and 29% needed care within 24 to 48 hours. Eleven percent of those who left were hospitalized within the next week, and three patients required emergency surgery. Nine percent of those who waited to be seen were hospitalized. Forty-nine percent of patients who left did not see a physician during the 1-week follow-up period. CONCLUSION Overcrowding in this public hospital's emergency department restricts access to needed ambulatory medical care for the poor and uninsured.

The deteriorating administrative efficiency of the U.S. health care system.

Abstract: Background and Methods. In 1983 the proportion of health care expenditures consumed by administration in the United States was 60 percent higher than in Canada and 97 percent higher than in Britain. To assess the effects of recent health policy initiatives on the administrative efficiency of health care, we examined four components of administrative costs in the United States and Canada for 1987: insurance overhead, hospital administration, nursing home administration, and physicians' billing and overhead expenses. Most data were provided by the two nations' federal health and statistics agencies, supplemented by state and provincial data and published sources. Because data on physicians' billing costs were limited, we estimated a range for these costs by two methods that rely on different sources of data. All figures are reported in 1987 U.S. dollars. Results. In 1987 health care administration cost between $96.8 billion and $120.4 billion in the United States, amounting to 19.3 to 24.1 percent ...

Patient Compliance in Medical Practice and Clinical Trials

Abstract: Patient noncompliance with medical regimens is a major factor in therapeutic failure and is particularly detrimental to clinical trials. This text aims to address the entire scope of compliance issues, and describes electronic monitoring devices that record actual dose times. Traditional methods of assessing compliance, such as patient history, drug levels, and counting pills or prescription refills, are also discussed. The review of everyday clinical problems facing practitioners everywhere is complemented by discussions on the impact of noncompliance in research and the drug regulatory process. Health care providers in all fields as well as clinical trial researchers should find useful ideas throughout the book.

Controlling variation in health care: a consultation from Walter Shewhart.

Abstract: The control of unintended variation is an objective central to modern industrial quality management methods, based largely on the theoretical work of Walter A. Shewhart. As industrial quality management techniques find their place in health care, professionals may feel threatened by the effort to reduce variation. Understanding may reduce this fear. Variation of the types addressed in quality control efforts erodes quality and reliability, and adds unnecessarily to costs. Such undesirable variation derives, for example, from misinterpretation of random noise in clinical data, from unreliability in the performance of clinical and support systems intended to support care, from habitual differences in practice style that are not grounded in knowledge or reason, and from the failure to integrate care across the boundaries of components of the health care system. Quality management efforts can successfully reduce each of these forms of variation without insult to the professional autonomy, dignity, or purpose of health care professionals. Professionals need to embrace the scientific control of variation in the service of their patients and themselves.

Gastrointestinal Surgery for Severe Obesity.

Abstract: The National Institutes of Health Consensus Development Conference on Gastrointestinal Surgery for Severe Obesity brought together surgeons, gastroenterologists, endocrinologists, psychiatrists, nutritionists, and other health care professionals as well as the public to address the nonsurgical treatment options for severe obesity, the surgical treatments for severe obesity and the criteria for selection, the efficacy and risks of surgical treatments for severe obesity, and the need for future research on and epidemiological evaluation of these therapies. Following 2 days of presentations by experts and discussion by the audience, a consensus panel weighed the evidence and prepared their consensus statement. Among their findings, the panel recommended that 1) patients seeking therapy for severe obesity for the first time should be considered for treatment in a nonsurgical program with integrated components of a dietary regimen, appropriate exercise, and behavioral modification and support, 2) gastric restrictive or bypass procedures could be considered for well-informed and motivated patients with acceptable operative risks, 3) patients who are candidates for surgical procedures should be selected carefully after evaluation by a multidisciplinary team with medical, surgical, psychiatric, and nutritional expertise, 4) the operation be performed by a surgeon substantially experienced with the appropriate procedures and working in a clinical setting with adequate support for all aspects of management and assessment, and 5) lifelong medical surveillance after surgical therapy is a necessity. The full text of the consensus panel's statement follows.

Predictors of successful aging: a twelve-year study of Manitoba elderly.

Abstract: In Manitoba, Canada, a representative cohort of elderly individuals ages 65 to 84 (n = 3,573) were interviewed in 1971 and the survivors of this cohort were reinterviewed in 1983 This analysis assesses the determinants of successful aging--whether or not an individual will live to an advanced age, continue to function well at home, and remain mentally alert Over 100 separate indicators of demographic and socio-economic status, social supports, health and mental status in 1971 were available as potential predictors of successful aging Indicators of access to health care over the period 1970-82 and indicators of diseases over this period were also available as predictors Those who aged successfully were shown to have greater satisfaction with life in 1983 and to have made fewer demands on the health care system than those who aged less well Despite the large number of potential predictors of successful aging which were examined, only age, four measures of health status, two measures of mental status, and not having one's spouse die or enter a nursing home were shown to be predictive of successful aging

The Measles Epidemic: The Problems, Barriers, and Recommendations

Abstract: The nation has experienced a marked increase in measles cases during 1989 and 1990. Almost one half of all cases have occurred in unvaccinated preschool children, mostly minorities. The principal cause for the epidemic is failure to provide vaccine to vulnerable children on schedule. Major reasons for the low vaccine coverage exist within the health care system itself, which creates barriers to obtaining immunization and fails to take advantage of many opportunities to provide vaccines to children. Ideally, immunizations should be given as part of a comprehensive child health care program. However, immunization cannot await the development of such an ideal system. Essential changes can and should be made now. Specific recommendations include improved availability of immunization; improved management of immunization services; improved capacity to measure childhood immunization status; implementation of the two-dose measles vaccine strategy; and laboratory, epidemiologic, and operational studies to further define the determinants of decreased vaccine coverage and to develop new combinations of vaccines that can be administered earlier in life. The measles epidemic may be a warning flag of problems with our system of primary health care. (JAMA. 1991;266:1547-1552)

Panic Attacks in the Community: Social Morbidity and Health Care Utilization

Abstract: This article focuses on social morbidity and health care utilization in persons with panic attacks not meeting full diagnostic criteria for panic disorder. The findings are based on data from a random sample of over 18 000 adults drawn from five US communities. Panic attacks not meeting full criteria for panic disorder have a relatively high lifetime prevalence (3.6% of the adult population). Persons with panic attacks had impairment in perceived physical and emotional health, and in occupational and financial functioning, increased use of health care facilities, emergency departments, and psychoactive drugs. Persons with panic attacks were intermediate in severity between those with panic disorder and those with other psychiatric disorders. The findings could not be explained by comorbidity with other psychiatric disorders. We conclude that panic attacks have clinical significance and are associated with substantial morbidity. (JAMA. 1991;265:742-746)

Consequences of queuing for care at a public hospital emergency department.

Abstract: Objective. —To determine whether the length of a queue at a public hospital emergency department was associated with increased likelihood of patients' leaving without being seen by a physician and whether leaving adversely affected patients' health or affected their subsequent use of health care services. Design. —Observational cohort. Patients were surveyed during 1 week in July 1990 and received a follow-up survey 7 to 14 days later. The responses of patients who left without being seen by a physician were compared with those who were seen by a physician. Setting. —Emergency department at San Francisco (Calif) General Hospital. Patients. —All English-, Spanish-, and Cantonese-speaking adults waiting for emergency care were eligible. Of 882 eligible individuals, 700 agreed to participate; 85% of enrolled subjects saw a physician and 15% left without being seen. Demographic characteristics of patients who were and who were not seen were not significantly different. Main Outcome Measures. —Emergency department waiting time and changes in patients' self-reported health. Results. —Patients were more likely to leave as waiting times increased. At follow-up, patients who left without being seen were twice as likely as those who were seen to report that their pain or the seriousness of their problem was worse. Only 4% of patients who left required subsequent hospitalization, but 27% returned to an emergency department. Conclusion. —Many patients can appropriately decide whether their problem is truly urgent and make alternative plans in the face of long waits, but the health of some patients may be jeopardized by long queues for emergency care. ( JAMA . 1991;266:1091-1096)

Avoiding bias in the conduct and reporting of cost-effectiveness research sponsored by pharmaceutical companies.

Abstract: Because of the growing focus on containing health care costs, pharmaceutical companies are trying to demonstrate the cost effectiveness of their products relative to alternatives. In Europe and Aus...

Too far to walk: maternal mortality in context.

Abstract: This article briefly capsules some of the thinking about obstacles obstetrics patients encounter on the way to a care facility which is based on over 200 research studies or articles. The bibliography is available on request and not included in the article. Delay in seeking care is presented in 3 ways. The 1st is in the decision to seek care and discussion is presented in Newsletter 35. The 2nd delay is in reaching a facility after the decision is made which is the subject of this article. The 3rd delay is in receiving the needed care and will appear in Newsletter 37. Based on interviews of rural Kenyan women of the 47% intending to deliver in a hospital only 36% actually did so. Distance and unavailability of public transportation in other studies were expressed as obstacles that prevented women from reaching the hospital. There is not systematic documentation in the literature of these types of delays. Consequently programs which identify high risk women for hospital delivery and raising community awareness may be ineffective if there is inaccessibility of the facility. Urban areas have better access to health facilities and there is uneven distribution in rural areas even in developed countries such as Portugal. The example of an equitably distributed health network exists in Cuba. The implications of the shortage of health facilities and health care providers and the uneven distribution are that limited access interferes with usage. The nature of the terrain and the condition of the roads and the actual distances are considerations. Many inhabitants must walk or improvise a means of transportation to reach health care because there is a scarcity of public transportation. The patients condition may deteriorate on the way which makes treatment more difficult provided the patient is still alive upon arrival. An example is given of a Tanzanian women bleeding to death waiting for a taxi. A decision to seek care may be timely but impaired access prevented utilization. An additional complication is a situation where the nearest facility is not equipped to treat the condition or even administer essential first aid. A further delay occurs in transporting the patient to the proper facility. Death enroute data is scarce and may be included in home deaths but maternal mortality study data is available.

Innovation in health care teams.

Abstract: While there has been much research on organizational innovation and on individual creativity, little research has examined the social psychological factors predicting work group innovation. In this exploratory study, using a new measure of innovativeness, eight health care teams were studied. Members of five ‘innovative’ and three ‘traditional’ teams (comprising 43 health care professionals) completed questionnaires examining aspects of individual and group work experience, and produced inventories of innovation reports. On the basis of these inventories, team innovativeness was rated by experienced health care professionals. Team innovation was predicted by climate for innovation (in particular tolerance of diversity), team commitment and team collaboration. The content of health care team innovations was also examined to reveal current trends.

Key Determinants of Consumer Satisfaction With General Practice

Abstract: Consumer satisfaction is an increasingly important issue, both in the evaluation and the shaping of health care, yet the relationship between specific criteria of health care and overall levels of consumer satisfaction with primary care is rarely addressed. The study reported here, based upon the results of a postal questionnaire of a random sample of adults in the south east of England (response rate 62%, n = 454), attempts to address this issue. Whilst general levels of satisfaction were high (95%), questions of a more detailed and specific nature revealed greater levels of dissatisfaction (e.g. 38% felt unable to discuss personal problems with their GP, 26% expressed dissatisfaction with the level of information they received, and 25% were dissatisfied with the length of time spent in consultation). Key dimensions such as communication (0.64; p less than 0.001), the nature and quality of the doctor-patient relationship (0.61; p less than 0.001) and the GP's professional skills (0.58; p less than 0.001)--vis-a-vis issues such as access, availability and type of service provision--were found to be the criteria which were most strongly associated with overall levels of satisfaction with general practice. The policy implications of these findings in the light of the recent Government White Papers, Promoting Better Health and Working for Patients, are discussed.

Head injuries: costs and consequences

Abstract: Head injuries are costly in terms of lives lost, productivity losses, and health care expenditures. This article develops an economic model that is used to estimate the lifetime cost of all head injuries sustained in 1985 that resulted in hospitalization or death. Included are the costs of medical services, productivity lost because of illness and disability, and mortality costs resulting from premature death. These estimates are presented by age, gender, and severity of injury. The cost of head injuries is compared with the cost of all injuries. The need for better data on the incidence, health care needs, and service utilization of head-injured persons is noted.

Short-term mortality predictions for critically ill hospitalized adults: science and ethics.

Abstract: Modern life-sustaining therapy often succeeds in postponing death but may be ineffective at restoring health. Decisions that influence the time and circumstances of an individual's death are now common and require an accurate and comprehensive characterization of likely outcome. Evaluation of alternative outcomes requires acknowledgement that most patients find some outcomes to be worse than death. Improved understanding of major predictors of patient outcome, combined with rapidly expanding technical abilities to collect and manipulate large amounts of detailed clinical data, have created a new intellectual and technical basis for estimating outcomes from intensive medical care. Such objective probability estimates, such as the system described here, can reduce uncertainty about difficult clinical decisions and can be used by physicians, patients, and society to reorient health care toward more scientifically and ethically defensible approaches.

National health systems of the world

Abstract: PART I: RESOURCES 1. Physicians and Healers 2. Nurses, Pharmacists, and Other Personnel 3. Health Facilities 4. Health Commodities and Knowledge PART II: PROGRAMS 5. Governmental Health Agencies 6. Social Security for Medical Care 7. Voluntary Health Agencies 8. Private Sector Health Care PART III: ECONOMIC SUPPORT MANAGEMENT 9. Economic Support of Health Systems 10. Health Planning and Administration 11. Health Regulation and Legislation PART IV: HEALTH SERVICES DELIVERY 12. Ambulatory and Primary Health Care 13. Hospital Services 14. Special Purpose Health Programs PART V: WORLD PERSPECTIVE 15. International Health Activities 16. World Trends in Health Systems

Gender Disparities in Clinical Decision Making

Abstract: RECENT evidence has raised concerns that women are disadvantaged because of inadequate attention to the research, diagnosis, and treatment of women's health care problems. In 1985, the US Public Health Service's Task Force on Women's Health Issues reported that the lack of research data on women limited understanding of women's health needs. 1 One concern is that medical treatments for women are based on a male model, regardless of the fact that women may react differently to treatments than men or that some diseases manifest themselves differently in women than in men. The results of medical research on men are generalized to women without sufficient evidence of applicability to women. 2-4 For example, the original research on the prophylactic value of aspirin for coronary artery disease was derived almost exclusively from research on men, yet recommendations based on this research have been directed to