Showing papers on "Health care published in 1992"

The need for a new medical model: A challenge for biomedicine.

Abstract: The dominant model of disease today is biomedical, and it leaves no room within tis framework for the social, psychological, and behavioral dimensions of illness. A biopsychosocial model is proposed that provides a blueprint for research, a framework for teaching, and a design for action in the real world of health care.

Measuring Functioning and Well-Being: The Medical Outcomes Study Approach

Abstract: Measuring Functioning and Well-Being is a comprehensive account a broad range of self-reported functioning and well-being measures developed for the Medical Outcomes Study, a large-sale study of how patients fare with health care in the United States. This book provides a set of ready-to-use generic measures that are applicable to all adults, including those well and chronically ill, as well as a methodological guide to collecting health data and constructing health measures. As demand increases for more practical methods to monitor the outcomes of health care, this volume offers a timely and valuable contribution to the field. The contributors address conceptual and methodological issues involved in measuring such important health status concepts as: physical, social, and role functioning; psychological distress and well-being; general health perceptions; energy and fatigue; sleep; and pain. The authors present psychometric results and explain how to administer, score, and interpret the measures. Comprising the work of a number of highly respected scholars in the field of health assessment, Measuring Functioning and Well-Being will be of great interest and value to the growing number of researchers, policymakers, and clinicians concerned with the management and evaluation of health care.

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.

Guidelines for Clinical Practice: From Development to Use

Abstract: Guidelines for the clinical practice of medicine have been proposed as the solution to the whole range of current health care problems. This new book presents the first balanced and highly practical view of guidelines--their strengths, their limitations, and how they can be used most effectively to benefit health care.The volume offers Recommendations and a proposed framework for strengthening development and use of guidelines. Numerous examples of guidelines. A ready-to-use instrument for assessing the soundness of guidelines. Six case studies exploring issues involved when practitioners use guidelines on a daily basis. With a real-world outlook, the volume reviews efforts by agencies and organizations to disseminate guidelines and examines how well guidelines are functioning--exploring issues such as patient information, liability, costs, computerization, and the adaptation of national guidelines to local needs.

The Institute of Medicine.

Abstract: IN 1863 the National Academy of Sciences (NAS) was established by federal charter to advise the government on scientific matters. Almost 100 years later, in 1971, the Academy created the Institute of Medicine within the NAS to focus on health-related problems and issues. Today the IOM has a program budget of about $13 million, which includes both private and government funds, and is regarded as a leading center for health policy research. After briefly explaining the structure and general goals of IOM, this article describes several new or anticipated projects as well as some recently completed reports that have a strong ethical component. THE IOM The IOM's distinguished membership is made up of health care professionals of all sorts, scientists working in health-related disciplines, and lawyers, economists, and others knowledgeable in and involved with policies and activities associated with health issues. It is organized around eight working groups or divisions: Health Sciences Policy; Health Care Services; Health Promotion and Disease Prevention, including AIDS activities; International Health; Biobehavioral Sciences and Mental Disorders; the Food and Nutrition Board; the Medical Follow-up Agency; and the Health Policy Fellowship Programs. Each of these divisions is assisted by an oversight board that provides advice on its activities. It is important to know at the outset that IOM has decided that each of the divisions will include consideration of human values and ethical issues in their activities. Therefore, no separate locus was established within the IOM to deal with these matters. I am director of the Division of Health Sciences Policy, which is the only division that has made ethics a priority in its work, and it is the focus of this article.

An economic evaluation of asthma in the united states

Abstract: Background. Asthma is a common chronic illness. Recently, increases in morbidity and mortality due to this disease have been reported. We studied the distribution of health care resources used for asthma in order to lay the groundwork for further policy decisions aimed at reducing the economic burden of this disorder. Methods. Estimates of direct medical expenditures and indirect costs (in 1985 dollars) were derived from data available from the National Center for Health Statistics. These cost estimates were projected to 1990 dollars. Results. The cost of illness related to asthma in 1990 was estimated to be $6.2 billion. Inpatient hospital services represented the largest single direct medical expenditure for this chronic condition, approaching $1.6 billion. The value of reduced productivity due to loss of school days represented the largest single indirect cost, approaching $1 billion in 1990. Although asthma is often considered to be a mild chronic illness treatable with ambulatory care, we fo...

Evidence for the effectiveness of CME. A review of 50 randomized controlled trials.

Abstract: Objective. —To assess the impact of diverse continuing medical education (CME) interventions on physician performance and health care outcomes. Data Sources. —Usingcontinuing medical educationand related phrases, we performed regular searches of the indexed literature (MEDLINE, Social Science Index, the National Technical Information Service, and Educational Research Information Clearinghouse) from 1975 through 1991. In addition, for these years, we used manual searches, key informants, and requests to authors to locate other indexed articles and the nonindexed literature of adult and continuing professional education. Study Selection. —From the resulting database we selected studies that met the following criteria: randomized controlled trials; educational programs, activities, or other interventions; studies that included 50% or more physicians; follow-up assessments of at least 75% of study subjects; and objective assessments of either physician performance or health care outcomes. Data Extraction. —Studies were reviewed for data related to physician specialty and setting. Continuing medical education interventions were classified by their mode(s) of activity as being predisposing, enabling, or facilitating. Using the statistical tests supplied by the original investigators, physician performance outcomes and patient outcomes were classified as positive, negative, or inconclusive. Data Synthesis. —We located 777 CME studies, of which 50 met all criteria. Thirty-two of these analyzed physician performance; seven evaluated patient outcomes; 11 examined both measures. The majority of the 43 studies of physician performance showed positive results in some important measures of resource utilization, counseling strategies, and preventive medicine. Of the 18 studies of health care outcomes, eight demonstrated positive changes in patients' health care outcomes. Conclusion. —Broadly defined CME interventions using practice-enabling or reinforcing strategies consistently improve physician performance and, in some instances, health care outcomes. (JAMA1992;268:1111-1117)

Flow in Computer-Mediated Communication Electronic Mail and Voice Mail Evaluation and Impacts

Abstract: This study investigates the effects of multiple variables on user evaluation and perceived impacts of electronic mail and voice mail systems. It introduces flow as an important construct that characterizes perceptions of employee interactions with computer-mediated communication technologies as more or less playful and exploratory. Flow is hypothesized to be influenced by the technology (higher for electronic mail), ease of use, and computer skill. It is also proposed that flow, type of technology, perceived technology characteristics (ease of use), and organizational factors (management support, communication partners' medium use) positively influence employee evaluations and perceived impacts. A field survey was conducted at a large health care firm that had recently adopted both electronic mail and voice mail. The LISREL results provide mixed support for the hypotheses.

Functional reach : Predictive validity in a sample of elderly male veterans

Abstract: Focus groups were used to explore a range of issues concerning breast cancer screening in elderly women and to contribute to defining a research agenda. Two groups consisted of women aged 65-75 and 75 and older, and one group consisted of primary care physicians. Predominant topic areas were women's awareness of breast cancer and screening information, attitudes and perceived barriers to screening (including those related to women themselves, to the health care system, and to physicians), issues related to relationships within the medical community, and opinions about and priorities for change.

The accuracy of Medicare's hospital claims data: progress has been made, but problems remain.

Abstract: BACKGROUND. Health care databases provide a widely used source of data for health care research, but their accuracy remains uncertain. We analyzed data from the 1985 National DRG Validation Study, which carefully reabstracted and reassigned ICD-9-CM diagnosis and procedure codes from a national sample of 7050 medical records, to determine whether coding accuracy had improved since the Institute of Medicine studies of the 1970s and to assess the current coding accuracy of specific diagnoses and procedures. METHODS. We defined agreement as the proportion of all reabstracted records that had the same principal diagnosis or procedure coded on both the original (hospital) record and on the reabstracted record. We also evaluated coding accuracy in 1985 using the concepts of diagnostic test evaluation. RESULTS. Overall, the percentage of agreement between the principal diagnosis on the reabstracted record and the original hospital record, when analyzed at the third digit, improved from 73.2% in 1977 to 78.2% in ...

Quality of life measures in health care. I: Applications and issues in assessment.

Abstract: Many clinicians remain unsure of the relevance of measuring quality of life to their clinical practice. In health economics quality of life measures have become the standard means of assessing the results of health care interventions and, more controversially, the means of prioritising funding; but they have many other applications. This article--the first of three on measuring quality of life--reviews the instruments available and their application in screening programmes, audit, health care research, and clinical trials. Using the appropriate instrument is essential if outcome measures are to be valid and clinically meaningful.

How to break bad news : a guide for health care professionals

Abstract: For many health care professionals and social service providers, the hardest part of the job is breaking bad news. The news may be about a condition that is life-threatening (such as cancer or AIDS), disabling (such as multiple sclerosis or rheumatoid arthritis), or embarrassing (such as genital herpes). To date medical education has done little to train practitioners in coping with such situations. With this guide Robert Buckman and Yvonne Kason provide help. Using plain, intelligible language they outline the basic principles of breaking bad new and present a technique, or protocol, that can be easily learned. It draws on listening and interviewing skills that consider such factors as how much the patient knows and/or wants to know; how to identify the patient's agenda and understanding, and how to respond to his or her feelings about the information. They also discuss reactions of family and friends and of other members of the health care team. Based on Buckman's award-winning training videos and Kason's courses on interviewing skills for medical students, this volume is an indispensable aid for doctors, nurses, psychotherapists, social workers, and all those in related fields.

Care = organisation + physical labour + emotional labour

Abstract: The formula‘care = organisation + physical labour + emotional labour' identifies component parts of ‘carework’ as they were observed at a hospice. A comparison between women's domestic carework and that of the hospice nurses is made firstly to clarify the component elements of care and secondly to show how the interrelation and balance of the components differs in the two settings. It is argued that family care has been a model for hospice care but that division of labour in hospices, which replicates hospital labour-divisions, results in an inflexibility in hospice care which is incompatible with the ‘family’ model. In the final section it is suggested that emotional labour is likely to be increasingly recognised as part of health care but that the concept of ‘total care’ needs to be questioned.

Comparative measurement sensitivity of short and longer health status instruments.

Abstract: Short measures of health status are used increasingly in health services research, yet their sensitivities to clinical change have not been compared with longer, established instruments. In this study, 5 health status measures were administered preoperatively and 3 months postoperatively to 54 patients undergoing total hip arthroplasty. These instruments included the Sickness Impact Profile (SIP)--an established, long measure--and 4 short forms: the SF-36, Functional Status Questionnaire, shortened Arthritis Impact Measurement Scales, and Modified Health Assessment Questionnaire. Scores for physical, psychological, and global dimensions were constructed by aggregating subscales. Sensitivity to change, or responsiveness, was expressed with the standardized response mean (SRM), calculated as the mean change in score divided by the standard deviation of the change in score. The sampling distribution of the SRM was estimated with a jackknife procedure. Preoperative scores were moderately to highly correlated across instruments. The physical and global dimension SRMs of the brief health status measures ranged from 0.85 to 1.27 and were as large as or larger than the corresponding SIP SRMs. The SIP had the highest SRM on the psychological dimension. None of the instruments was significantly more sensitive than the others at the critical value (P = 0.005) adjusted for multiple comparisons. The brief health status measures were equally or more responsive than the SIP after total hip arthroplasty in the physical and global dimensions. Much larger samples are required to demonstrate statistically significant differences in SRMs among instruments.

Primary Care: Concept, Evaluation, and Policy

Abstract: Section I: Primary Care: Concept and Goals. 1: What is primary care?. 2: A basis for evaluating primary care. Section II: Elements of Primary Care. 3: First contact care and gatekeepers. 4: Longitudinality and managed care. 5: Comprehensiveness and benefit packages. 6: Coordination and the processes of referral. Section III: Primary Care in the United States. 7: Characteristics of practice and practitioners. 8: Organization, financing, and access to services. Section IV: Issues in Primary Care. 9: What type of physicians should provide primary care. 10: Medical records and information systems in primary care. 11: Physician-patient interactionsin primary care. 12: Quality assessment and quality improvement. 13: Community oriented primary care. Section V: Primary Care Systems. 14: Evaluation of primary care programs. 15: Cross-national comparisons of primary care. 16: A research agenda. 17: A policy agenda and epilogue

Interdisciplinarity: History, Theory, and Practice

Abstract: Medicine has evolved from the undertaking of the individual practitioner to a state in which many disciplines become involved in administering both diagnostic and treatment services. It has become a standard of care in hospital and clinic-based practice to utilize a multidisciplinary approach to medical care. Multidisciplinary modes of practice, however, do not ensure that participants interact cooperatively, or with the exclusive purpose of patient benefit. The usual mode of interaction within medical academic and clinical environments promotes individualism, protectionism, and some degree of isolation, not infrequently to the detriment of patient care. The stated purpose of this book is to provide a synthesis of theories and methodologies that promote a growing permeability of boundaries and that allow for intellectual accommodation. Health care professionals have been turning to interdisciplinary intervention approaches for several reasons, but the most compelling in medicine is the need to solve problems that are beyond the

Psychological Interventions for Cancer Patients to Enhance the Quality of Life

Abstract: Although the thrust of the nation’s cancer objectives for the year 2000 is prevention and screening, each year approximately 1 million Americans are diagnosed and must cope with the disease and treatments. They do so with the aid of family, friends, and the health care system, but accumulating data suggest that psychological interventions may be important for reducing emotional distress, enhancing coping, and improving “adjustment.” Experimental and quasi-experimental studies of psychological interventions are reviewed, and discussion of treatment components and mechanism is offered. A final section discusses future research directions and challenges to scientific advance.

Continuity of care in general practice: effect on patient satisfaction.

Abstract: OBJECTIVE--To evaluate the influence of continuity of care on patient satisfaction with consultations. DESIGN--Direct and episodic specific evaluation of patient satisfaction with recent consultation. SETTING AND SUBJECTS--A representative sample of 3918 Norwegian primary care patients were asked to evaluate their consultations by filling in a questionnaire. The response rate was 78%. MAIN OUTCOME MEASURES--The patient's overall satisfaction with the consultation was rated on a six point scale. Continuity of care was recorded as the duration and intensity of the present patient-doctor relationship and as patients' perception of the present doctor being their personal doctor or not. RESULTS--The multivariate analysis indicated that an overall personal patient-doctor relationship increased the odds of the patient being satisfied with the consultation sevenfold (95% confidence interval 4.9 to 9.9) as compared with consultations where no such relationships existed. The duration of the patient-doctor relationship had a weak but significant association with patient satisfaction, while the intensity of contacts showed no such association. CONCLUSION--Personal, continuous care is linked with patient satisfaction. If patient satisfaction is accepted as an integral part of quality health care, reinforcing personal care may be one way of increasing this quality.

Measuring mental health needs

Abstract: Cv's annual careers guide Tracks gives information of 150 professions in the UK, from communications media to banking, construction industry, financial services, healthcare, insurance, law, leisure & tourism, manufacturing, marketing, planning, and public services. Qualifications are listed from GCSE and GNVQ to degree level; there are work descriptions and salary grades, with interviews and advice from chartered institutes and individuals established in the particular field. The new edition includes contacts for working in countries in the European Union and comprehensive internet addresses with recruitment sites for each profession. The new edition notes expanded opportunities in environmental areas such as planning and estate management, as well as in organic production where niche companies are making rapid inroads to general distribution. Recorded interviews with chartered institutes and individuals are included in the new Tracks CD, giving valuable insights to the current state of access to particular professions.

The lab versus the clinic. Effects of child and adolescent psychotherapy.

Abstract: Four recent meta-analyses, involving more than 200 controlled outcome studies, have shown consistent evidence of beneficial therapy effects with children and adolescents. However, most of the studies involved experimental procedures, nonreferred subjects, specially trained therapists with small caseloads, and other features that may not represent conventional clinic therapy. Research focused on more representative treatment of referred clients in clinics has shown more modest effects; in fact, most clinic studies have not shown significant effects. Interpretation studies have not shown significant effects. Interpretation of these findings requires caution; such studies are few and most could profit from improved methodology. The clinic studies do raise questions as to whether the positive lab findings can be generalized to the clinics where most therapy occurs; however, the lab interventions that have worked so well may point the way to enhanced therapy effects in clinics.

No Longer Patient: Feminist Ethics and Health Care

Abstract: Acknowledgments Introduction Part I: Theoretical Beginnings 1. Understanding Feminism 2. Ethics, "Feminine" Ethics, and Feminist Ethics 3. Feminism and Moral Relativism 4. Toward a Feminist Ethics of Health Care Part II: Traditional Problems in Health Care Ethics 5. Abortion 6. New Reproductive Technologies 7. Paternalism 8. Research Part III: Feminist Expansions of the Bioethics Landscape 9. Ascriptions of Illness 10. Medical Constructions of Sexuality 11. Gender, Race, and Class in the Delivery of Health Care Notes References Index

Long-term effects of an educational program for general practitioners given by the Swedish Committee for the Prevention and Treatment of Depression.

Abstract: In 1983-1984 the Swedish Committee for the Prevention and Treatment of Depression offered an educational program on diagnosis and treatment of depressive disorders to all general practitioners on the island of Gotland. The program has been carefully evaluated; 1982 was used as the baseline and the main evaluation was carried out in 1985. After the educational programs, the frequency of sick leave for depressive disorders decreased, the frequency of inpatient care for depressive disorders decreased to 30% of that at the baseline; the prescription of antidepressants increased, but prescription of major tranquilizers, sedatives and hypnotics decreased. The frequency of suicide on the island decreased significantly. This study describes the long-term effects. In 1988, 3 years after the project ended, the inpatient care for depressive disorders increased, the suicidal rate returned almost to baseline values and the prescription of antidepressants stabilized. Thus, the effects were strictly related in time to the educational programs, indicating that the effects were real and not only a coincidence with local trends on Gotland. Furthermore, the results indicate that educational programs that can have pronounced effects on the health care system have to be repeated approximately every 2 years if long-term effects are to be expected.

Utilization of maternal health-care services in Peru: the role of women's education.

Abstract: The hypothesis that maternal education influences use of maternal health care services in Peru was analyzed by 4 logistic regression models using data from the Peruvian Demographic and Health Survey of September-December 1986. Peru has one of the highest child-mortality rates in the region with extreme variation across regions of the country ranging from 34/1000 in Lima to 110/1000 in the Andean mountains. The conceptual framework for this study was the health-seeking model of Kroger who proposed that utilization depends on predisposing factors including education characteristics of the illness and of the health-care system. This study analyzed 1925 births the last births to 4999 ever-married women in the 5 years before the survey. The 2 dependent variables were sources of prenatal care and assistance at delivery. 60.1% of the women had formal prenatal care and 54.9% had formal delivery assistance for their last birth. The bivariate effects of maternal schooling were strongly associated with use of health care with relative odds of 47.47 for delivery assistance and 25.37 for prenatal care. Controlling for the womans childhood background in Model 2 reduced the odds to 13.6 and 19.69 respectively. In model 3 access to care reduced relative odds to 8.33 for prenatal care and 10.70 for delivery assistance. Taking into account the household socioeconomic status in Model 4 reduced significance of the results. The results indicated that maternal education has a profound effect on seeking medical care but in Peru the lack of access to care in the outlying rural areas supersedes maternal education.

The Effects of Problem-Based Learning On Problem Solving

Abstract: Problem-based instruction is designed to provide students with a guided experience in solving an ill-structured problem. All learning in problem-based instruction stems from students initial questions about a problem situation. Currently used in medical school programs, problem-based curriculum has not been tested at the high school level. Science, Society and the Future (SSF) is an experimental problem-based course for gifted high school students. In the interdisciplinary course, students examine the meaning and impact of current science issues (the effect of electromagnetic fields on childhood leukemia, the health care system). In this study, SSF students and a group of comparison students were tested to determine changes in their spontaneous use of problem-solving steps as they consider an ill-structured problem. Results show some significant changes for the SSF group not observed in the comparison group.