Showing papers on "Health care published in 2001"

Crossing the Quality Chasm: A New Health System for the 21st Century

Abstract: Crossing the Quality Chasm identifies and recommends improvements in six dimensions of health care in the U.S.: patient safety, care effectiveness, patient-centeredness, timeliness, care efficiency, and equity. Safety looks at reducing the likelihood that patients are harmed by medical errors. Effectiveness describes avoiding over and underuse of resources and services. Patient-centeredness relates both to customer service and to considering and accommodating individual patient needs when making care decisions. Timeliness emphasizes reducing wait times. Efficiency focuses on reducing waste and, as a result, total cost of care. Equity looks at closing racial and income gaps in health care.

EQ-5D: a measure of health status from the EuroQol Group.

Abstract: Established in 1987, the EuroQol Group initially comprised a network of international, multilingual and multidisciplinary researchers from seven centres in Finland, the Netherlands, Norway, Sweden and the UK. Nowadays, the Group comprises researchers from Canada, Denmark, Germany, Greece, Japan, New Zealand, Slovenia, Spain, the USA and Zimbabwe. The process of shared development and local experimentation resulted in EQ-5D, a generic measure of health status that provides a simple descriptive profile and a single index value that can be used in the clinical and economic evaluation of health care and in population health surveys. Currently, EQ-5D is being widely used in different countries by clinical researchers in a variety of clinical areas. EQ-5D is also being used by eight out of the first 10 of the top 50 pharmaceutical companies listed in the annual report of Pharma Business (November/December 1999). Furthermore, EQ-5D is one of the handful of measures recommended for use in cost-effectiveness analyses by the Washington Panel on Cost Effectiveness in Health and Medicine. EQ-5D has now been translated into most major languages with the EuroQol Group closely monitoring the process.

Improving Chronic Illness Care: Translating Evidence Into Action

Abstract: The growing number of persons suffering from major chronic illnesses face many obstacles in coping with their condition, not least of which is medical care that often does not meet their needs for effective clinical management, psychological support, and information. The primary reason for this may be the mismatch between their needs and care delivery systems largely designed for acute illness. Evidence of effective system changes that improve chronic care is mounting. We have tried to summarize this evidence in the Chronic Care Model (CCM) to guide quality improvement. In this paper we describe the CCM, its use in intensive quality improvement activities with more than 100 health care organizations, and insights gained in the process.

Systematic reviews in health care: Assessing the quality of controlled clinical trials

Abstract: This is the first in a series of four articles The quality of controlled trials is of obvious relevance to systematic reviews. If the “raw material” is flawed then the conclusions of systematic reviews cannot be trusted. Many reviewers formally assess the quality of primary trials by following the recommendations of the Cochrane Collaboration and other experts. 1 2 However, the methodology for both the assessment of quality and its incorporation into systematic reviews and meta-analysis are a matter of ongoing debate.3-5 In this article we discuss the concept of study quality and the methods used to assess quality. #### Components of internal and external validity of controlled clinical trials Internal validity —extent to which systematic error (bias) is minimised in clinical trials Quality is a multidimensional concept, which could relate to the design, conduct, and analysis of a trial, its clinical relevance, or quality of reporting.6 The validity of the findings generated by a study clearly is an important dimension of quality. In the 1950s the social scientist Campbell proposed a useful distinction between internal and external validity (see box below). 7 8 Internal validity implies that the differences observed between groups of patients allocated to different …

Mental Health: A Report of the Surgeon General

Abstract: The past century has witnessed extraordinary progress in our improvement of the public health through medical sciencea nd ambitious, often innovative, approachest o health care services.P revious Surgeons General reports have saluted our gains while continuing to set ever higher benchmarks for the public health. Through much of this era of great challenge and greater achievement, however, concerns regarding mental illness and mental health too often were relegated to the rear of our national consciousness. Tragic and devastating disorders such as schizophrenia, depression and bipolar disorder, Alzheimer’s disease, the mental and behavioral disorders suffered by children, and a range of other mental disorders affect nearly one in five Americans in any year, yet continue too frequently to be spoken of in whispers and shame. Fortunately, leaders in the mental health field-fiercely dedicated advocates, scientists, government officials, and consumers-have been insistent that mental health flow in the mainstream of health. I agree and issue this report in that spirit. This report makes evident that the neuroscience of mental health-a term that encompasses studies extending from molecular events to psychological, behavioral, and societal phenomena-has emerged as one of the most exciting arenas of scientific activity and human inquiry. We recognize that the brain is the integrator of thought, emotion, behavior, and health. Indeed, one of the foremost contributions of contemporary mental health research is the extent to which it has mended the destructive split between “mental’ and “physical” health.

Mental Health: Culture, Race, and Ethnicity—A Supplement to Mental Health: A Report of the Surgeon General

Abstract: Mental health is fundamental to health, according to Mental Health: A Report of the Surgeon General, the first Surgeon General’s report ever to focus exclusively on mental health. That report of two years ago urged Americans to view mental health as paramount to personal well-being, family relationships, and successful contributions to society. It documented the disabling nature of mental illnesses, showcased the strong science base behind effective treatments, and recommended that people seek help for mental health problems or disorders. The first mental health report also acknowledged that all Americans do not share equally in the hope for recovery from mental illnesses. This is especially true of members of racial and ethnic minority groups. That awareness galvanized me to ask for a supplemental report on the nature and extent of disparities in mental health care for racial and ethnic minorities and on promising directions for the elimination of these disparities. This Supplement documents that the science base on racial and ethnic minority mental health is inadequate; the best available research, however, indicates that these groups have less access to and avail-ability of care, and tend to receive poorer quality mental health services. These disparities leave minority communities with a greater disability burden from unmet mental health needs. A hallmark of this Supplement is its emphasis on the role that cultural factors play in mental health. The cultures from which people hail affect all aspects of mental health and illness, including the types of stresses they confront, whether they seek help, what types of help they seek, what symptoms and concerns they bring to clinical attention, and what types of coping styles and social supports they possess. Likewise, the cultures of clinicians and service systems influence the nature of mental health services.

Bias, Discrimination, and Obesity

Abstract: This article reviews information on discriminatory attitudes and behaviors against obese individuals, integrates this to show whether systematic discrimination occurs and why, and discusses needed work in the field. Clear and consistent stigmatization, and in some cases discrimination, can be documented in three important areas of living: employment, education, and health care. Among the findings are that 28% of teachers in one study said that becoming obese is the worst thing that can happen to a person; 24% of nurses said that they are "repulsed" by obese persons; and, controlling for income and grades, parents provide less college support for their overweight than for their thin children. There are also suggestions but not yet documentation of discrimination occurring in adoption proceedings, jury selection, housing, and other areas. Given the vast numbers of people potentially affected, it is important to consider the research-related, educational, and social policy implications of these findings.

The challenge of complexity in health care

Abstract: This is the first in a series of four articles Across all disciplines, at all levels, and throughout the world, health care is becoming more complex. Just 30 years ago the typical general practitioner in the United Kingdom practised from privately owned premises with a minimum of support staff, subscribed to a single journal, phoned up a specialist whenever he or she needed advice, and did around an hour's paperwork per week. The specialist worked in a hospital, focused explicitly on a particular system of the body, was undisputed leader of his or her “firm,” and generally left administration to the administrators. These individuals often worked long hours, but most of their problems could be described in biomedical terms and tackled using the knowledge and skills they had acquired at medical school. You used to go to the doctor when you felt ill, to find out what was wrong with you and get some medicine that would make you better. These days you are as likely to be there because the doctor (or the nurse, the care coordinator, or even the computer) has sent for you. Your treatment will now be dictated by the evidence—but this may well be imprecise, equivocal, or conflicting. Your declared values and preferences may be used, formally or informally, in a shared management decision about your illness. The solution to your problem is unlikely to come in a bottle and may well involve a multidisciplinary team. Not so long ago public health was the science of controlling infectious diseases by identifying the “cause” (an alien organism) and taking steps to remove or contain it. Today's epidemics have fuzzier boundaries (one is even known as “syndrome X”1): they are the result of the interplay of genetic predisposition, environmental context, and lifestyle choices. The experience of …

What is e-health?

Abstract: Everybody talks about e-health these days, but few people have come up with a clear definition of this comparatively new term. Barely in use before 1999, this term now seems to serve as a general "buzzword," used to characterize not only "Internet medicine", but also virtually everything related to computers and medicine. The term was apparently first used by industry leaders and marketing people rather than academics. They created and used this term in line with other "e-words" such as e-commerce, e-business, e-solutions, and so on, in an attempt to convey the promises, principles, excitement (and hype) around e-commerce (electronic commerce) to the health arena, and to give an account of the new possibilities the Internet is opening up to the area of health care. Intel, for example, referred to e-health as "a concerted effort undertaken by leaders in health care and hi-tech industries to fully harness the benefits available through convergence of the Internet and health care." Because the Internet created new opportunities and challenges to the traditional health care information technology industry, the use of a new term to address these issues seemed appropriate. These "new" challenges for the health care information technology industry were mainly (1) the capability of consumers to interact with their systems online (B2C = "business to consumer"); (2) improved possibilities for institutionto-institution transmissions of data (B2B = "business to business"); (3) new possibilities for peerto-peer communication of consumers (C2C = "consumer to consumer").

The RAND/UCLA Appropriateness Method User's Manual

Abstract: : The concepts of appropriate and necessary care are fundamental to the creation of an efficient and equitable health-care delivery system Evidence of inappropriate overuse and underuse of procedures has been documented even in health systems characterised by the absence of global budgets, capitation, utilisation review or the pressure of requiring a second opinion Health systems should function in such a way that inappropriate care is progressively reduced, while appropriate and especially necessary care are maintained or increased The ability to determine and identify which care is overused and which is underused is essential to this functioning To this end, the "RAND/UCLA Appropriateness Method" (here given the acronym RAM) was developed by RAND and UCLA in the 198Os It has been further developed and refined in North America and, increasingly, in Europe

Changing provider behavior: an overview of systematic reviews of interventions.

Abstract: Background.Increasing recognition of the failure to translate research findings into practice has led to greater awareness of the importance of using active dissemination and implementation strategies. Although there is a growing body of research evidence about the effectiveness of different strateg

Patient adherence to treatment: three decades of research: a comprehensive review

Abstract: Low compliance to prescribed medical interventions is an ever present and complex problem, especially for patients with a chronic illness With increasing numbers of medications shown to do more good than harm when taken as prescibed, low compliance is a major problem in health care Relevant studies were retrieved through comprehensive searches of different database systems to enable a thorough assessment of the major issues in compliance to prescribed medical interventions The term compliance is the main term used in this review because the majority of papers reviewed used this term Three decades have passed since the first workshop on compliance research It is timely to pause and to reflect on the accumulated knowledge The enormous amount of quantitative research undertaken is of variable methodological quality, with no gold standard for the measurement of compliance and it is often not clear which type of non-compliance is being studied Many authors do not even feel the need to define adherence Often absent in the research on compliance is the patient, although the concordance model points at the importance of the patient's agreement and harmony in the doctor-patient relationship The backbone of the concordance model is the patient as a decision maker and a cornerstone is professional empathy Recently, some qualitative research has identified important issues such as the quality of the doctor-patient relationship and patient health beliefs in this context Because non-compliance remains a major health problem, more high quality studies are needed to assess these aspects and systematic reviews/meta-analyses are required to study the effects of compliance in enhancing the effects of interventions

Consumer health information seeking on the Internet: the state of the art

Abstract: Increasingly, consumers engage in health information seeking via the Internet. Taking a communication perspective, this review argues why public health professionals should be concerned about the topic, considers potential benefits, synthesizes quality concerns, identifies criteria for evaluating online health information and critiques the literature. More than 70 000 websites disseminate health information; in excess of 50 million people seek health information online, with likely consequences for the health care system. The Internet offers widespread access to health information, and the advantages of interactivity, information tailoring and anonymity. However, access is inequitable and use is hindered further by navigational challenges due to numerous design features (e.g. disorganization, technical language and lack of permanence). Increasingly, critics question the quality of online health information; limited research indicates that much is inaccurate. Meager information-evaluation skills add to consumers' vulnerability, and reinforce the need for quality standards and widespread criteria for evaluating health information. Extant literature can be characterized as speculative, comprised of basic 'how to' presentations, with little empirical research. Future research needs to address the Internet as part of the larger health communication system and take advantage of incorporating extant communication concepts. Not only should research focus on the 'net-gap' and information quality, it also should address the inherently communicative and transactional quality of Internet use. Both interpersonal and mass communication concepts open avenues for investigation and understanding the influence of the Internet on health beliefs and behaviors, health care, medical outcomes, and the health care system.

Making health care safer: a critical analysis of patient safety practices.

Abstract: Objectives Patient safety has received increased attention in recent years, but mostly with a focus on the epidemiology of errors and adverse events, rather than on practices that reduce such events This project aimed to collect and critically review the existing evidence on practices relevant to improving patient safety Search strategy and selection criteria Patient safety practices were defined as those that reduce the risk of adverse events related to exposure to medical care across a range of diagnoses or conditions Potential patient safety practices were identified based on preliminary surveys of the literature and expert consultation This process resulted in the identification of 79 practices for review The practices focused primarily on hospitalized patients, but some involved nursing home or ambulatory patients Protocols specified the inclusion criteria for studies and the structure for evaluation of the evidence regarding each practice Pertinent studies were identified using various bibliographic databases (eg, MEDLINE, PsycINFO, ABI/INFORM, INSPEC), targeted searches of the Internet, and communication with relevant experts Data collection and analysis Included literature consisted of controlled observational studies, clinical trials and systematic reviews found in the peer-reviewed medical literature, relevant non-health care literature and "gray literature" For most practices, the project team required that the primary outcome consist of a clinical endpoint (ie, some measure of morbidity or mortality) or a surrogate outcome with a clear connection to patient morbidity or mortality This criterion was relaxed for some practices drawn from the non-health care literature The evidence supporting each practice was summarized using a prospectively determined format The project team then used a predefined consensus technique to rank the practices according to the strength of evidence presented in practice summaries A separate ranking was developed for research priorities Main results Practices with the strongest supporting evidence are generally clinical interventions that decrease the risks associated with hospitalization, critical care, or surgery Many patient safety practices drawn primarily from nonmedical fields (eg, use of simulators, bar coding, computerized physician order entry, crew resource management) deserve additional research to elucidate their value in the health care environment The following 11 practices were rated most highly in terms of strength of the evidence supporting more widespread implementation Appropriate use of prophylaxis to prevent venous thromboembolism in patients at risk; Use of perioperative beta-blockers in appropriate patients to prevent perioperative morbidity and mortality; Use of maximum sterile barriers while placing central intravenous catheters to prevent infections; Appropriate use of antibiotic prophylaxis in surgical patients to prevent postoperative infections; Asking that patients recall and restate what they have been told during the informed consent process; Continuous aspiration of subglottic secretions (CASS) to prevent ventilator-associated pneumonia; Use of pressure relieving bedding materials to prevent pressure ulcers; Use of real-time ultrasound guidance during central line insertion to prevent complications; Patient self-management for warfarin (Coumadin) to achieve appropriate outpatient anticoagulation and prevent complications; Appropriate provision of nutrition, with a particular emphasis on early enteral nutrition in critically ill and surgical patients; and Use of antibiotic-impregnated central venous catheters to prevent catheter-related infections Conclusions An evidence-based approach can help identify practices that are likely to improve patient safety Such practices target a diverse array of safety problems Further research is needed to fill the substantial gaps in the evidentiary base, particularly with regard to the generalizability of patient safety practices heretofore tested only in limited settings and to promising practices drawn from industries outside of health care

Nurses' Reports On Hospital Care In Five Countriese ways in which nurses' work is structured have left nurses

Abstract: The current nursing shortage, high hospital nurse job dissatisfac- tion, and reports of uneven quality of hospital care are not uniquely American phenomena. This paper presents reports from 43,000 nurses from more than 700 hospitals in the United States, Canada, England, Scotland, and Germany in 1998-1999. Nurses in countries with distinctly different health care systems report similar shortcomings in their work environments and the quality of hospital care. While the competence of and relation between nurses and physi- cians appear satisfactory, core problems in work design and workforce manage- ment threaten the provision of care. Resolving these issues, which are amena- ble to managerial intervention, is essential to preserving patient safety and care of consistently high quality.

Nurses’ Reports On Hospital Care In Five Countries

Abstract: The current nursing shortage, high hospital nurse job dissatisfaction, and reports of uneven quality of hospital care are not uniquely American phenomena. This paper presents reports from 43,000 nurses from more than 700 hospitals in the United States, Canada, England, Scotland, and Germany in 1998-1999. Nurses in countries with distinctly different health care systems report similar shortcomings in their work environments and the quality of hospital care. While the competence of and relation between nurses and physicians appear satisfactory, core problems in work design and workforce management threaten the provision of care. Resolving these issues, which are amenable to managerial intervention, is essential to preserving patient safety and care of consistently high quality.

Narrative Medicine: A Model for Empathy, Reflection, Profession, and Trust

Abstract: The effective practice of medicine requires narrative competence, that is, the ability to acknowledge, absorb, interpret, and act on the stories and plights of others. Medicine practiced with narrative competence, called narrative medicine, is proposed as a model for humane and effective medical practice. Adopting methods such as close reading of literature and reflective writing allows narrative medicine to examine and illuminate 4 of medicine's central narrative situations: physician and patient, physician and self, physician and colleagues, and physicians and society. With narrative competence, physicians can reach and join their patients in illness, recognize their own personal journeys through medicine, acknowledge kinship with and duties toward other health care professionals, and inaugurate consequential discourse with the public about health care. By bridging the divides that separate physicians from patients, themselves, colleagues, and society, narrative medicine offers fresh opportunities for respectful, empathic, and nourishing medical care.

Systematic Reviews in Health Care

Abstract: An output voltage wave having a desired amplitude and frequency is formed from selected portions of the AC signal generated by an induction generator. The selected portions of the generated signal are chosen in such a fashion as to establish the phase angle of the current drawn from the induction generator at a value that results in an appropriate excitation current being provided for the induction generator. Control arrangements are utilized to determine the required phase angle for the current drawn from the induction generator and to determine the portions of the generated signal that must be utilized to provide such a phase angle. Establishing the phase angle of the current drawn from the induction generator is accomplished without affecting the phase angle of the output current, which is determined by the load.

Chronic disease self-management program: 2-year health status and health care utilization outcomes.

Abstract: Objectives.To assess the 1- and 2-year health status, health care utilization and self-efficacy outcomes for the Chronic Disease Self-Management Program (CDSMP). The major hypothesis is that during the 2-year period CDSMP participants will experience improvements or less deterioration than expected

Effect of a Self- Management Program on Patients with Chronic Disease

Abstract: CONTEXT. For patients with chronic disease, there is growing interest in "self-man- agement" programs that emphasize the patients' central role in managing their ill- ness. A recent randomized clinical trial demonstrated the potential of self-manage- ment to improve health status and reduce health care utilization in patients with chronic diseases. OBJECTIVE. To evaluate outcomes of a chronic disease self-management program in a "real-world" setting. STUDY DESIGN. Before-after cohort study. PATIENTS AND SETTING. Of the 613 patients from various Kaiser Permanente hospitals and clinics recruited for the study, 489 had complete baseline and follow-up data. INTERVENTION. The Chronic Disease Self-Management Program is a 7-week, small- group intervention attended by people with different chronic conditions. It is taught largely by peer instructors from a highly structured manual. The program is based on self-efficacy theory and emphasizes problem solving, decision making, and confi- dence building. MAIN OUTCOME MEASURES. Health behavior, self-efficacy (confidence in ability to deal with health problems), health status, and health care utilization, assessed at baseline and at 12 months by self-administered questionnaires. RESULTS. At 1 year, participants in the program experienced statistically significant improvements in health behaviors (exercise, cognitive symptom management, and communication with physicians), self-efficacy, and health status (fatigue, shortness of breath, pain, role function, depression, and health distress) and had fewer visits to the emergency department (ED) (0.4 visits in the 6 months prior to baseline, compared with 0.3 in the 6 months prior to follow-up; P = 0.05). There were slightly fewer out- patient visits to physicians and fewer days in hospital, but the differences were not statistically significant. Results were of about the same magnitude as those observed in a previous randomized, controlled trial. Program costs were estimated to be about $200 per participant. CONCLUSIONS. We replicated the results of our previous clinical trial of a chronic dis- ease self-management program in a "real-world" setting. One year after exposure to the program, most patients experienced statistically significant improvements in a variety of health outcomes and had fewer ED visits.

Knee pain and osteoarthritis in older adults: a review of community burden and current use of primary health care

Abstract: BACKGROUND Osteoarthritis is the single most common cause of disability in older adults, and most patients with the condition will be managed in the community and primary care. AIM To discuss case definition of knee osteoarthritis for primary care and to summarise the burden of the condition in the community and related use of primary health care in the United Kingdom. DESIGN Narrative review. METHOD A literature search identified studies of incidence and prevalence of knee pain, disability, and radiographic osteoarthritis in the general population, and data related to primary care consultations. Findings from UK studies were summarised with reference to European and international studies. RESULTS During a one year period 25% of people over 55 years have a persistent episode of knee pain, of whom about one in six in the UK and the Netherlands consult their general practitioner about it in the same time period. The prevalence of painful disabling knee osteoarthritis in people over 55 years is 10%, of whom one quarter are severely disabled. CONCLUSION Knee osteoarthritis sufficiently severe to consider joint replacement represents a minority of all knee pain and disability suffered by older people. Healthcare provision in primary care needs to focus on this broader group to impact on community levels of pain and disability.

Improving the quality of health care in the United Kingdom and the United States: a framework for change.

Abstract: Fueled by public incidents and growing evidence of deficiencies in care, concern over the quality and outcomes of care has increased in both the United Kingdom and the United States. Both countries have launched a number of initiatives to deal with these issues. These initiatives are unlikely to achieve their objectives without explicit consideration of the multilevel approach to change that includes the individual, group/team, organization, and larger environment/system level. Attention must be given to issues of leadership, culture, team development, and information technology at all levels. A number of contingent factors influence these efforts in both countries, which must each balance a number of tradeoffs between centralization and decentralization in efforts to sustain the impetus for quality improvement over time. The multilevel change framework and associated properties provide a framework for assessing progress along the journey.

Trust in physicians and medical institutions: what is it, can it be measured, and does it matter?

Abstract: Despite the profound and pervasive importance of trust in medical settings, there is no commonly shared understanding of what trust means, and little is known about what difference trust actually makes, what factors affect trust, and how trust relates to other similar attitudes and behaviors. To address this gap in understanding, the emerging theoretical, empirical, and public policy literature on trust in physicians and in medical institutions is reviewed and synthesized. Based on this review and additional research and analysis, a formal definition and conceptual model of trust is presented, with a review of the extent to which this model has been confirmed by empirical studies. This conceptual and empirical understanding has significance for ethics, law, and public policy.

The RAND-36 measure of health-related quality of life

Abstract: The RAND-36 is perhaps the most widely used health-related quality of life (HRQoL) survey instrument in the world today. It is comprised of 36 items that assess eight health concepts: physical functioning, role limitations caused by physical health problems, role limitations caused by emotional problems, social functioning, emotional well-being, energy/fatigue, pain, and general health perceptions. Physical and mental health summary scores are also derived from the eight RAND-36 scales. This paper provides example applications of the RAND-36 cross-sectionally and longitudinally, provides information on what a clinically important difference is for the RAND-36 scales, and provides guidance for summarizing the RAND-36 in a single number. The paper also discusses the availability of the RAND-36 in multiple languages and summarizes changes that are incorporated in the latest version of the survey.

Inherited haemoglobin disorders: an increasing global health problem.

Abstract: Despite major advances in our understanding of the molecular pathology, pathophysiology, and control and management of the inherited disorders of haemoglobin, thousands of infants and children with these diseases are dying through lack of appropriate medical care. This problem will undoubtedly increase over the next 20 years because, as the result of a reduction in childhood mortality due to infection and malnutrition, more babies with haemoglobin disorders will survive to present for treatment. Although WHO and various voluntary agencies have tried to disseminate information about these diseases, they are rarely mentioned as being sufficiently important to be included in setting health care priorities for the future. It takes considerable time to establish expertise in developing programmes for the control and management of these conditions, and the lessons learned in developed countries will need to be transmitted to those countries in which they occur at a high frequency.