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PubMed2001

A moral economy of American medicine in the managed-care era.

The moral economy of American medicine has been transformed by contentious innovations in organization, administration, regulation, and finance. In many settings old fee-for-service incentives and disincentives have been replaced by those of "managed care", while in other settings they have been diluted or distorted. In the everyday care of patients, old and new may alternate or interact. These innovations may also be having secondary effects on participation in life-sciences research and the development and employment of new technologies, discouraging collective support for preliminary investigation and delaying adoption of improved goods and services until cost-reducing potential has already been realized. This motivational complexity, particularly in its moral dimensions, is hard to address using standard assumptions and methods. I argue for different assumptions, based on the clinical behavior of individual patients rather than the market behavior of aggregated consumers, and I describe a different method, based on an old idea in political economy. I then present a new way to explain the core obligations of clinicians, researchers, and planners and to interpret the policy problems they must now share.

Fee-for-Service Plans↗
PubMed2004

Cultural feasibility assessment of tuberculosis prevention among persons of Haitian origin in South Florida.

A cultural feasibility study was conducted among persons of Haitian origin in South Florida to identify factors which might influence utilization of screening and treatment services for latent tuberculosis infection in this population. Five focus group interviews conducted among men and women explored cultural beliefs and practices related to TB, barriers and incentives to screening, and approaches to increasing treatment adherence. Key findings include the influence of social stigma and fears related to confidentiality of medical status as disincentives to screening. Cultural sensitivity to being labeled as a high risk group for these infections also emerged as a critical variable. Community-based approaches to health education for this population are described. Study recommendations include the planning of programs based on a service delivery model that stresses respect and personal attention to clients, improved interpersonal skills of health center staff, and coordination of services between private doctors and public health agencies.

Attitude to Health↗
PubMed2003

[Change in perspective. One's profession from the viewpoint of others: how do nurses feel they are being perceived by physicians in professional interactions?].

Collaboration between nursing personnel and physicians (and vice versa) on a medical ward is a fragile issue. There seems to be a need to rebuild this collaboration whenever there is a change of staff on the ward. This act can consume valuable resources and is basically influenced by the image of nursing personnel, and physicians among the other profession, respectively. This article presents the findings based on 18 interviews with physicians (eleven males/seven females), and 25 interviews with nursing personnel (five males/20 females) from two units of internal medicine of two confessional academic hospitals each with ca. 350 beds in a big city in Northern Germany. Both occupational groups experienced the reflection of their own professional image in a different way. Physicians seemed to be rather ignorant where their image among the nursing staff is concerned. In their answers they talked about qualifications of nurses in general and did not reflect upon their own image among nursing personnel. Nursing personnel often expected a social and a professional feedback from the physicians in spite of the fact that physicians are not experts in nursing. This may be due to the lack of a professional (not organizational) hierarchical context for the nursing personnel. The deficit of an own organizational structure of supervision, incentives and disincentives weakens the position of nurses in the context of a hospital.

Adult↗
PubMed2000

Laparoscopic live donor nephrectomy: pre-operative assessment of technical difficulty.

Laparoscopic live donor nephrectomy decreases disincentives to live kidney donation. Thus, many centers are interested in adopting this procedure. However, the high stakes involved for both the donor and the recipient, and the technical difficulties of the operation, have tempered the enthusiasm of some surgeons. Ideally, if early in their series, surgeons could select patients that would be the least challenging technically, it would facilitate the dissemination of this operation. The purpose of this study is to determine if anatomic or radiologic parameters can accurately assess pre-operatively the degree of technical difficulty of laparoscopic live donor nephrectomy for any individual patient. Abdominal spiral three-dimensional CT scanning was performed prior to laparoscopic donor nephrectomy. CT scans were reviewed for six radiographic anatomic parameters. Seven clinical anatomic measurements relating to body habitus were recorded upon induction anesthesia at the time of surgery. Demographic data for gender, age, race, weight, height, and smoking history were collected. Following laparoscopic live donor nephrectomy, the following six component parts of the operation were graded on a scale of 1-4 (1 = easy, 4 = very difficult) for technical difficulty: a) mobilization of the colon; b) mobilization of the upper pole; c) dissection of the renal vein; d) dissection of the renal artery; e) division of the adrenal vein; and f) dissection of the ureter. Also, operative time, estimated blood loss, and intra-operative fluid requirements were recorded as surrogate markers of operative difficulty. Forty-one patients were included in the study. Laparoscopic donor nephrectomy was successfully completed in all cases. The sum of the difficulty scores was 9.9+/-3.1 (mean) (range, 6-18). No anatomic, demographic, or radiologic parameters were predictive of the total operative difficulty score. Of the surrogate markers, only operative time correlated with total difficulty score (R = 0.47, p = 0.003). Donor weight and abdominal girth correlated with operative time (R = 0.50, p = 0.002; R = 0.38, p = 0.019) but not with total difficulty score (R = 0.10, p = 0.51; R = -0.02, p = 0.90, respectively). When the easiest cases and the hardest cases (< or = 25th percentile and > or =75th percentile total difficulty score, respectively) were segregated out, again no anatomic, demographic, or radiologic parameters were predictive of operative technical difficulty. In conclusion, laparoscopic live donor nephrectomy technical difficulty could not be predicted by body habitus from the variables examined in this study. Hence, it was equally likely that performing laparoscopic live donor nephrectomy using a heavy donor would be technically easy, as using a thin donor would be difficult. Although, in general, operative time increased with donor size and weight, it appears that laparoscopic live donor nephrectomy operative technical difficulty is dependent upon such factors as amount of laparoscopic working space, quality of tissue planes, and retractability of the colon and mesocolon; factors that, to date, are not quantifiable.

Adult↗
PubMed1994

Reproductive rights and reproductive behavior. Clash or convergence of private values and public policies?

Using a rational scientific approach upholding public health values, this article notes experience gained from 25 years of cooperative transnational research on reproductive behavior. An overview of world population trends is followed by discussions of reproductive rights as a human right, the utility of acceptability studies of modern methods of fertility regulation, and findings from research on psychological responses to abortion, long-term developmental effects of compulsory pregnancy, and the use of incentives and disincentives to influence family size. There is also consideration of the clash between private values and public policy on reproductive behavior in the United States and the convergence achieved in Denmark and the Netherlands, where rates of unintended pregnancy are among the world's lowest.

Abortion, Legal↗
PubMed1999

Factors influencing the diagnosis and management of teeth with pulpal and periradicular disease by general dental practitioners. Part 2.

OBJECTIVE: To identify techniques commonly used in the management of periradicular disease by general dental practitioners and to ascertain views on continuing professional education in endodontics. DESIGN: Data was collected via a postal questionnaire distributed to 617 general dental practitioners in Scotland (33% of practitioners registered with the Dental Practice Board). RESULTS: 417 (69%) questionnaires were completed and returned. Only 24.9% of respondents used rubber dam routinely. The majority of respondents used hand instruments for preparation with either sodium hypochlorite or local anaesthetic being used most frequently for irrigation. The mean time for treatment of a single rooted tooth was 71 minutes. The demand for continuing education courses was high with 340 and 197 respondents requesting endodontic and rubber dam courses, respectively. CONCLUSIONS: Traditional methods for preparing the root canal using hand instruments were favoured by most dentists. The major disincentive to the use of rotary instruments and new techniques for obturating with thermally softened gutta-percha was expense. The importance of rubber dam isolation requires reiteration and more continuing education courses are required to update clinical skills.

Dental Pulp Diseases↗
PubMed2000

Views of academic dentists about careers in academic dentistry in the United Kingdom.

The aim of this paper is to report the views of academic dentists about careers in academic dentistry assessed by method of a postal questionnaire survey. The subjects of the survey were dentists in academic posts in the United Kingdom. The incentives in pursuing an academic career which respondents rated most highly were the opportunity to teach and the variety of work in an academic career. The greatest disincentives were competing pressures from service work, teaching and research, and the difficulty of getting research grants. Many would like to spend more time on research and less on service work and teaching. The length of time required for training, and the quality of training, was a concern, particularly for junior academics. Most respondents rated the enjoyment of their job highly but scored much lower on satisfaction with the time their job left for domestic and leisure activities. By contrast with academic medicine, in academic dentistry there is typically greater emphasis on teaching and less on research. In conclusion, the balance of activities in academic posts, particularly between service work, teaching and research, needs to be regularly reviewed. The development of a more structured training programme for junior academics, which does not disadvantage academic dentists when compared with their NHS colleagues, may be required.

Attitude of Health Personnel↗
PubMed2001

Inequalities in availability of National Health Service general dental practitioners in England and Wales.

AIM: To model the inequalities in availability of National Health Service general dental practitioners in England and Wales in relation to key socio-demographic factors. METHODS: Current estimates of the numbers of NHS general dental practitioners for each health authority were related to data from the 1991 census using Poisson regression models, and generalised estimating equations to allow for correlation between results for neighbouring health authorities. RESULTS: An 'average' health authority, without a dental school, would be expected to have 2,138 residents for every NHS dentist. Controlling for relevant factors, health authorities with higher proportions of the following are associated with lower (better) population to dentist ratios by the amounts shown: each 1% higher female population (-11.8%; 95%CI -19.1%, -3.9% P = 0.004); each 1% greater South Asian population (-1.4%; 95%CI -2.1%, -0.7% P <0.001). A health authority with a dental school is associated with a more favourable ratio compared with one without such a facility (-9.2%; 95%CI -16.2%, -1.6% P = 0.019). Each additional 1% of the following are associated with a worse ratio by the amounts shown: children aged 0 to 14 years old (+5.2%; 95% CI +2.4%, +8.1% P < 0.001); adults aged over 65 years old (+2.8%, 95%CI +1.0%, +4.7% P =0.002); households without a car (+0.8%; 95%CI 0.0%, +1.6% P =0.042). CONCLUSIONS: Ensuring access to dental care may be a more complex issue than simply providing adequate numbers of dentists at a national level. Any manpower planning exercise should additionally consider local factors that may act as incentives or disincentives to those professionals who provide care.

Adolescent↗
PubMed2006

Development of an outpatient finger-prick glomerular filtration rate procedure suitable for epidemiological studies.

Development of an outpatient finger-prick glomerular filtration rate (GFR) procedure suitable for epidemiological studies. In clinical practice, reference GFR procedures are rarely used; in large-scale research studies, a great deal of effort and experience is required to obtain them, which is a considerable disincentive to using GFR as an end point. The major problem for both clinical staff and the subject is the length of time that the procedure takes, requiring continuous attendance in the outpatient clinic or its vicinity. Using iohexol as a marker, we therefore propose an alternative approach, which addresses this fundamental deterrent to a more widespread use of GFR measurement. Eighty-two GFR measurements were performed in a mixture of healthy subjects and patients with differing degrees of renal impairment with a wide range of GFRs. Serum was obtained from blood samples to enable a reference GFR to be calculated. Blood spots were collected on filter paper at the same intervals (120, 180, and 240 min), allowed to dry, and then sent through the post. Serum and blood spots were analyzed simultaneously for each individual by automated reverse-phase high-pressure liquid chromatography. Standard linear regression analyses confirmed a good agreement (r2 = 0.953) between the iohexol serum GFR and iohexol blood spots GFR. Bland-Altman analysis confirmed that there was no concentration bias. Paired comparisons (Wilcoxon's paired signed rank test) showed no significant difference between the two measurements. Capillary sampling is simple, effective, and significantly reduces the time and costs of performing plasma clearance GFR measurements. This approach will make the GFR measurement more accessible for clinical practice and large-scale epidemiological studies may become feasible.

Adult↗
PubMed1999

Vocational outcome following spinal cord injury.

STUDY DESIGN: Non-experimental (ex post facto) survey research design involving the use of a fixed alternative format questionnaire. OBJECTIVES: To investigate variables influencing vocational outcome, to identify barriers to gaining and sustaining employment and to identify the effects of variables on the type of work engaged in following spinal cord injury. The two sets of independent variables considered were, individual and injury-related factors (age at onset of injury, time since injury, extent/level of injury, highest educational qualification achieved pre-injury, and pre-injury occupation) and circumstantial factors (means of transport, access difficulties, perceived workplace discrimination, financial disincentives to work and perceived level of skill). SETTING: The Princess Alexandra Hospital Spinal Injuries Unit, Queensland, Australia. METHODS: Data on the variables and the vocational outcomes of having ever worked or studied post-injury, current employment status and post-injury occupation were obtained from survey responses. Demographical and medical data were gathered from medical records. RESULTS: Forward stepwise logistic regression revealed that having ever worked or studied post-injury was associated with all individual and injury-related factors except pre-injury occupation, and two circumstantial factors, namely means of transport and access difficulties. Current employment was associated with all circumstantial factors as well as age at injury and pre-injury occupation. Standard multiple regression analyses revealed that post-injury occupation was correlated with all individual and injury-related factors as well as means of transport and perceived workplace discrimination. CONCLUSIONS: Tailored rehabilitation programs for individuals with characteristics associated with less successful vocational outcomes may facilitate their employment status after injury.

Adolescent↗
PubMed2000

Accurate detection of male subclinical genital tract infection via cervical culture and DNA hybridization assay of the female partner.

The accuracy of the PACE2 DNA hybridization assay of the cervix and cervical culture in female partners for the diagnosis of male subclinical genital tract infection were assessed in a male infertility population. A total of 184 men were screened for the presence of Chlamydia trachomatis, Ureaplasma urealyticum and Mycoplasma hominis. Seventy-one men were identified with a positive test for one or more of the above mentioned micro-organisms. The overall prevalence of bacterial infection was 39%. Female partners of all men were tested with the PACE2 DNA hybridization assay to detect a C. trachomatis infection. Sensitivity was 100% and specificity was 100%. In 67 female partners (94%) of men who tested positive for U. urealyticum and/or M. hominis, a cervical swab culture was performed. The sensitivity of the cervical swab culture was 100%. In view of the high prevalence of U. urealyticum and M. hominis in the male genital tract and the role these sexually transmitted pathogens may play in infertility, one might question whether all couples should be screened for the presence of these pathogens. Transurethral swab culture after digital prostatic massage is disincentive to men. The cervical culture in their female partner, performed as part of the routine fertility work-up, is a suitable alternative to detect the presence of these micro-organisms in the male genital tract.

Adult↗
PubMed2000

Challenges in using rater judgements in medical education.

Changes in the healthcare environment are putting increasing pressure on medical schools to make faculty accountable and to document the quality of the medical education they provide. Faculty's ratings of students' performances and students' ratings of faculty's teaching are important elements in these efforts to document educational quality. This article discusses selected research related to factors affecting raters' judgements, analyses how changes in the health care environment are influencing such judgements, offers some suggestions to moderate some of the effects and links these influences to the system that upholds professional standards. Ratings are known to have a positive bias (generosity error), provide limited discrimination and often fail to document serious deficits. The potential sources of these problems relate to the mechanics of the rating task, the system used to obtain ratings and factors affecting rater judgement. As managed care demands reduce the time faculty have for teaching, as system-wide disincentives to provide negative ratings proliferate and as social engineering challenges, such as the Americans with Disabilities Act, impose differential standards for students, the natural tendency to avoid giving negative ratings becomes even harder to resist. Ultimately, these forces compromise the capability of faculty to uphold the standards of the profession. The author calls for a national effort to stem the erosion of those standards.

Clinical Competence↗
PubMed1999

Junior doctors' views about careers in academic medicine.

OBJECTIVE: To investigate junior doctors' views about careers in academic medicine. DESIGN: Postal questionnaire survey. SETTING: National Health Service in England. SUBJECTS: Doctors in university posts at specialist registrar level, Medical Research Council and Wellcome Trust training fellows, and specialist registrars in National Health Service posts. RESULTS: Incentives to pursue an academic career which respondents rated as strong related to the challenge of research and the intellectual environment of research units. The strongest disincentives were perceived difficulties in obtaining research grants and uncertainty regarding pay parity with National Health Service colleagues. Medical Research Council and Wellcome fellows had much more protected research time than other academic doctors but were less satisfied with their clinical training. Academic doctors who were not fellows reported spending less than half their time on research and the great majority agreed that their research suffers when there is pressure on the service side. CONCLUSIONS: The job content of academic posts should be kept under regular review to ensure that clinical service pressures do not inappropriately erode research time while also ensuring that postholders have adequate clinical training. Training programmes need flexibility to accommodate the needs of clinical academics in their progress through higher specialist training.

Attitude of Health Personnel↗
PubMed2003

Nonheart-beating kidney donation: current practice and future developments.

BACKGROUND: Nonheart-beating kidney donation (NHBD) is gaining acceptance as a method of donor pool expansion. However, a number of practitioners have concerns over rates of delayed graft function, acute rejection, and long-term graft survival. The ethical issues associated with NHBD are complex and may be a further disincentive. Tailored strategies for preservation, viability prediction, and immunosuppression for kidneys from this source have the potential to maximize the number of available organs. This review article presents the current practice of NHBD kidney transplantation, examines the results and draws comparisons with cadaveric kidneys, and explores some areas of potential development. METHODS: A review of the current literature on NHBD kidney donation was performed. RESULTS: The renewed interest in NHBD kidneys is driven by a continuing shortfall in available organs. Those centers involved in NHBD report an increase in kidney transplants of the order of 16% to 40% and there is no evidence that the financial costs are higher with NHBDs. The majority of experience comes from Maastricht category 2 NHBDs, where an estimation of warm time is possible. This is generally limited to 40 minutes. There are variations in the technique for kidney preservation prior to retrieval, but most centers use an aortic balloon catheter. Much work has looked at the ideal technique for kidney preservation prior to implantation. Evidence suggests that machine perfusion produces the best initial function rates, decreased use of adjuvant immunotherapy and fewer haemodialysis sessions than static cold storage. CONCLUSION: Despite being associated with poorer initial graft function, the long-term allograft survival of NHBD kidneys does not differ from the results of transplantation from cadaveric kidneys. Further, serum creatinine levels are generally equivalent. Constant reassessment of the ethical issues is required for donation to be increased while respecting public concerns. Use of viability assessment and tailoring of immune suppression for NHBD kidneys may allow a further increase in donation from this source.

Heart Arrest↗
PubMedDate not supplied

Increasing AV fistulas: revisiting a time-tested solution.

Despite having the lowest complication rate of all hemodialysis accesses, the prevalence of autologous arteriovenous (AV) fistulas has declined to 28% in the United States. The reasons for this decline include high early AV fistula failure rates, long maturation times, the frequent need for emergent dialysis, unavailable or poor pre-ESRD programs and planning, patient resistance to the realities of impending ESRD, and financial disincentives to AV fistula placement. Despite these barriers, programs throughout the country have demonstrated the ability to increase AV fistula prevalence to more than 50%. The strategies employed have included increased reliance on upper arm brachiocephalic and transposed basilic vein fistulas, the use of preoperative imaging to identify the best sites for fistula creation, and aggressive attempts at salvage of nonmaturing fistulas. Other groups have systematically and successfully replaced failed grafts with upper arm brachiocephalic or bracheobasilic fistulas. These experiences clearly show that exceeding the National Kidney Foundation Dialysis Outcomes Quality Initiative (NKF-DOQI) goal of more than 50% fistula placement is achievable in the United States. Declining numbers of AV fistulas are the result of a combination of factors, including changes in our patient population and learned practice patterns coupled with a failure of our delivery system to provide education, timely referral, and incentives for fistula placement. Increasing AV fistula prevalence in the United States is achievable and will improve patient outcomes and decrease the costs of ESRD.

Arteriovenous Shunt, Surgical↗
PubMedDate not supplied

Laparoscopic live donor nephrectomy: rationale, techniques, and implications.

Laparoscopic live donor nephrectomy (LDN) was conceived as a means for decreasing donor nephrectomy morbidity and reducing disincentives for kidney donation. Since LDN was first reported in 1995, explosive growth has led to its performance at more than 100 centers worldwide. Despite initial skepticism in some segments of the transplant community, the results of LDN have improved progressively so that it is emerging as a new standard of care for live kidney donation. We review the development and refinement of LDN and its current rationale and applications.

Humans↗
PubMedDate not supplied

Where are all the AV fistulas?

Increasing the prevalence of arteriovenous (AV) fistulas is crucial to decreasing the incidence and costs of dialysis access failure. Despite almost uniform agreement in the dialysis community of the need to increase AV fistulas, U.S. fistula prevalence has only increased modestly since the publication of the Dialysis Outcomes Quality Initiative (DOQI) clinical practice guidelines in 1997. Fistula rates of 28% in incident patients and 27% in prevalent patients [Health Care Finance Administration (HCFA) clinical performance measures project data for 1999] do not approach the fistula rates achieved by various focused U.S. programs, nor those routinely observed in Europe. Systemic barriers that limit the availability and funding of both pre-end-stage renal disease (ESRD) care and preoperative imaging, coupled with financial disincentives, lack of accountability, and educational deficiencies, impede progress toward increased fistula placement. Improvements in AV fistula prevalence require a realistic appraisal and correction of the system problems hindering achievement of this goal. The DOQI and Kidney Disease Outcomes and quality Initiative (K/DOQI) were excellent first steps; however, implementation will require modification of other structures that impact on patient care delivery.

Arteriovenous Shunt, Surgical↗
PubMed1996

Hospital-affiliated headache clinics in the managed care era.

Many headache clinics are affiliated with hospitals. These facilities were often started before the era of managed care. The new incentives and disincentives of managed care will force these programs to change their structures. Only those which document value are likely to survive.

Headache↗