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PubMed1991

Children's exposure to smoking.

Exposure to smoking and the attitudes of other people have, in many studies, been associated with an increase in smoking through childhood and adolescence. Previous studies which have examined the relative influence of parents, siblings and friends on young people smoking do not show the same pattern of results, indicating that parents and siblings who smoke may or may not have an influence above or beyond that of friends. In this study, the extent to which these sources of exposure influence young people is examined. A related hypothesis which is tested in this study is that the amount of exposure to smoking may be a factor which influences young people to smoke independent of the particular source of the influence. The pattern of results suggests that the source of the influence is more important than the extent of influence among friends and family members. In particular, the influence of friends' smoking was evident at ages 9 to 15 years to the exclusion of the parental example of smoking. Parental smokers may lead their children to try smoking but it seems unlikely that this is related to them smoking at a later age. While peer influence may result in smoking, the influence of parents or older people smoking may be becoming a disincentive in this time of changing attitudes to smoking.

Adolescent↗
PubMed1998

Competition through physician-managed care: the case for capitated multispecialty group practices.

The dominant managed care model in the USA is the individual practice association (IPA), in which physicians in separate practices contract with a health plan. One alternative model, the capitated multispecialty group practice (CMGP), has some distinct advantages: (i) the best randomized trial comparing a health management organization (HMO) with indemnity insurance showed equivalent health outcomes for a prepaid group-practice model HMO, with about a 40% saving in cost, mostly from lower hospital utilization. There is no comparable evidence for IPA-style HMO's; (ii) most managed care plans control costs through 'gatekeeper' primary care physicians or capitated payment. Strong financial disincentives to care, applied to small practices, lead to a significant risk of withholding needed care. Large capitated groups diffuse the risk among hundreds or thousands of physicians; (iii) small practices also lack the financial resources and expertise to develop information systems, continuous quality improvement programs, and other means of improving efficiency. Larger groups can integrate specialty and primary care, laboratory, pharmacy, information technology and other services, to improve quality and cost-effectiveness, while maintaining physician control of the process; (iv) in urban California, HMO enrollment in six large capitated groups increased by 91% from 1990 to 1994. Hospital utilization for these groups was less than half the USA average; (v) because it is self-insured, the CMGP could contract directly with purchasers, eliminating the need for the insurance intermediary. The CGMP offers an ethical, effective alternative that maintains the primacy of the physician in health care: physician-managed care.

California↗
PubMed2006

Incentives for voluntary HIV testing in NHS staff.

BACKGROUND: HIV seroprevalence is rising in the United Kingdom. While acceptability of HIV testing has been explored among many groups there is a paucity of data regarding voluntary HIV counselling and testing (VCT) among NHS staff. AIMS: To understand the barriers to HIV testing among NHS employees. To observe how these may be overcome. To assess which factors would motivate staff to undergo VCT and which would be a disincentive. METHODS: Completion of a cross-sectional anonymous postal questionnaire survey of new employees at a London district general hospital. Demographic and attitudinal factors were collected. Respondents were able to give multiple responses to questions regarding reasons for and against VCT. Those unable to communicate in English were excluded. RESULTS: There was a 63% response rate; of 69 respondents, 76% were female, 72% had English as their first language and 30% self-identified as white British. Thirty-nine percent were nurses, 19% doctors and the remainder a variety of professions. Of these, 41% had had a previous HIV test; none were known positive. Sixty-two percent would consider future testing. The commonest reasons to consider testing were knowledge of status (79%), treatment benefit (40%) and to inform family members (44%). The commonest reasons not to test were already tested negative (30%) and rather not know (26%). CONCLUSIONS: Since the NHS is recruiting staff from areas of high HIV prevalence, VCT should be encouraged. NHS staff require information on how to access testing as well as the benefits of early detection of blood-borne viruses.

AIDS Serodiagnosis↗
PubMed1998

Employment, attitudes toward work, and quality of life among people with schizophrenia in three countries.

This study examines attitudes toward work, work incentives, and the impact of work on quality of life for people with schizophrenia, and investigates whether these findings differ among Western countries. We interviewed 24 randomly selected subjects with schizophrenia and schizoaffective disorder (12 employed and 12 unemployed) at each of three sites: Boulder, Colorado, United States; Berlin, Germany; and Berne, Switzerland. No significant differences were found in the subjects' attitudes toward work or subjective well-being, although Swiss patients had a higher cost-of-living-adjusted income. Unemployed subjects reported a lower subjective reservation (minimum financially worthwhile) wage than employed subjects in Berlin and Berne, whereas the reverse was true in Boulder. When subjects from all sites were combined, employed patients displayed less psychopathology and significant advantages in terms of objective and subjective measures of income and well-being: They were also more likely to stress the importance of work. The results suggest that work is associated with a markedly better quality of life for people with schizophrenia, but that disability pension programs in the United States might introduce work disincentives.

Adult↗
PubMed1988

Financial risk, hospital cost, complications, and comorbidities in surgical noncomplication- and noncomorbidity-stratified diagnostic related groups.

The purpose of this study was to analyze resource consumption in the 147 non-complicating condition-stratified surgical diagnostic related groups (DRGs). Analysis of 2647 surgical patients in these non-CC-stratified surgical DRGs demonstrated that patients with more CCs per DRG generated higher total hospital costs, a longer hospital length of stay, a greater percentage of procedures per patient, financial risk under DRG payment, more outliers, and a higher mortality rates than patients in these same DRGs with fewer CCs. These findings suggest that the current DRG classification system may be inequitable to certain groups of patients or types of hospitals vis-à-vis the non-CC-stratified surgical DRGs. Financial disincentives to treat these patients may affect both their access and quality of care in the future.

Academic Medical Centers↗
PubMed2000

Laparoscopic donor nephrectomy with a 23-hour stay: a new standard for transplantation surgery.

OBJECTIVE: To determine the outcomes associated with laparoscopic donor nephrectomy (LDN) performed as a 23-hour day surgery protocol. SUMMARY BACKGROUND DATA: Living donor renal transplantation is associated with immediate graft function and prolonged graft survival. The recent application of laparoscopic technology to living renal donation has refocused attention on the advantages of this donor source. LDN is associated with decreased donor pain, length of stay, time out of work, and opportunity costs. The authors hypothesized that LDN would be a viable 23-hour stay procedure. METHODS: All living donation procedures since May 1998 have been performed with LDN. The 23-hour protocol was initiated in January 1999. LDNs performed from May 1998 to December 1998 and traditional open donor nephrectomy procedures from May 1996 to May 1998 served as historical controls. The following variables were examined: donor sex, related versus nonrelated donation, operative time, blood loss, length of stay, time out of work, recipient and donor serum creatinine levels, hospital charges, and complications. RESULTS: The 23-hour LDN protocol was associated with high degrees of donor satisfaction. Thirty-six of the 41 donors were discharged within 23 hours; 1 was readmitted. Time out of work was equivalent to that of the control group; graft function was identical among all three comparison groups. Hospital charges were equivalent between the control group and the open nephrectomy group and were significantly decreased in the 23-hour group. CONCLUSIONS: Laparoscopic donor nephrectomy can be performed as a 23-hour stay procedure without incurring additional complications or donor dissatisfaction. By further decreasing opportunity costs and disincentives for donation, LDN may increase the number of potential donors appearing for evaluation.

Adult↗
PubMed1997

The costs of managing advanced colorectal cancer: a broad perspective.

Cancer care is expensive, consuming between 5 and 10% of health-care resources in industrialized countries. Therefore increasing emphasis is being placed on the value of treatment interventions. Colorectal cancer is the second most common cancer in the Western world and nearly two-thirds of patients will require palliative treatment. Only limited data are available on the cost of palliative chemotherapy for patients with advanced disease. The profile of raltitrexed ('Tomudex', formerly ZD1694) suggests that it may reduce costs associated with the administration of chemotherapy. Recent studies demonstrate that the total monthly cost of raltitrexed is lower or about the same as a variety of commonly used 5-fluorouracil-based regimens and offers potential savings for hospitals in terms of demand on specialist facilities, physician, nursing and pharmacy time, and overnight bed occupancy. The personal cost borne by patients and their carers for travelling and time off work is reduced with raltitrexed compared with the widely used Mayo regimen. However, there may be disincentives within certain national health-care systems to the introduction of a more resource-efficient drug such as raltitrexed. Physicians will need information on both the benefits and costs of drug treatments to be able to make informed decisions on the provision of high quality, cost-effective patient care, and it is likely that health economic assessment will be incorporated into increasing numbers of clinical trials.

Antimetabolites, Antineoplastic↗
PubMed1991

Forty years of litigation involving residents and their training: I. General programmatic issues.

An analysis of reported state and federal adjudication from 1950 through 1989 was undertaken to identify issues and trends in litigation involving residents and their training. Of the 174 decisions cited, 38 (22%) involved disputes over general programmatic issues. The great majority of these addressed academic administration, especially issues arising from dismissals of residents. During more recent periods, residency programs have accommodated to judicial scrutiny of dismissals and have prevailed more often than claimants in litigation. Successful accommodation by residency programs has apparently not operated as a disincentive to further litigation, however.

Accreditation↗
PubMed1995

A quarter-century of experience with career change education: an option for turning specialists into generalists.

The Physician Refresher program, now 25 years old, at the Medical College of Pennsylvania offers training to clinically inactive physicians. The authors examined the characteristics of program participants to determine whether specialists who took the program to prepare for a change to a primary care career made the intended change. Application data from all registrants between 1982 and 1993 were compared with data on previously reported groups from 1968-1975 and 1976-1981. Specialist registrants' subsequent practice activities were documented from the AMA Medical Directory and the American Board of Medical Specialties Directory; a telephone survey elicited their reasons for making or not making the career change to primary care. During the last decade of the program women registrants constituted 36% of the total; international medical graduates (IMGs) 43%; and clinically inactive physicians 38%. Specialists outnumbered those in primary care by two to one. Although 65% of specialists planned to switch to primary care, ultimately only 27% of the total did so; many, especially the IMGs, were serving the disadvantaged. Those who did not switch cited a variety of disincentives, including individual educational needs not met by a general refresher course. If the medical profession accepts the need to devise programs that "retool" specialists to provide primary care, those programs should be specifically designed to address the individual needs of the specialists involved. Concomitantly, the incentives to make the switch need to be enhanced.

Adult↗
PubMed1999

Debt management and financial planning support for primary care students and residents at Boston University School of Medicine.

Boston University Medical Center created the Office of Residency Planning and Practice Management as part of The Robert Wood Johnson Foundation's Generalist Physician Initiative. Since 1995, the office has improved the medical center's ability to promote and support the generalist career decisions of its students and residents by removing indebtedness as a disincentive. After a brief review of the relationship between indebtedness and specialty selection, the authors delineate the nature and volume of debt-management assistance provided by the office to students and residents through individual counseling sessions, workshops, and other means between April 1995 and March 1998. A case study shows the progression of these services throughout residency training. The medical center also coordinates its debt-management assistance with counseling from physician-oriented financial planning groups. In conclusion, the authors discuss several characteristics of a successful debt-management program for residents.

Boston↗
PubMed1999

Rating educational quality: factors in the erosion of professional standards.

Changes in the health care 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' judgments, analyzes how changes in the health care environment are influencing such judgments, 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 judgment. 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.

Academic Medical Centers↗
PubMed2000

The scholarship of application.

The scholarship of application encompasses a broad range of different types of scholarship in the sciences and humanities that involves translation of new knowledge to practical applications to solve problems of individuals and of society. The authors discuss this form of scholarship broadly, but focus on how it applies to patient-oriented research and to service performed by physicians. They distinguish between a clinician's use of his or her expertise (not scholarship) and a clinician's activities such as systematically assessing the effectiveness of different techniques and communicating the findings in a way that allows others to benefit (scholarship). They (1) review the importance of scholarship of application (i.e., society depends on the application of new knowledge), with special attention to the benefits to academic institutions; (2) discuss incentives for such scholarship (e.g., readiness of funding for directly applicable research) and disincentives (e.g., shortcomings in methods; lower prestige); (3) explain how it should be evaluated (create a more expansive peer-review process); (4) explain how it should be rewarded (rewards should be similar to those given for other forms of scholarship); and (5) describe how it should be nurtured (rigorous training in methodology, protected time for research, tangible support). They conclude that the interdependence of academic institutions and of society requires that the scholarship of application be conducted with rigor and relevance, and that institutions must develop strategies to promote applied scholarship.

Clinical Medicine↗
PubMed2006

Meeting the challenges facing clinical research: solutions proposed by leaders of medical specialty and clinical research societies.

The development of a robust national clinical research enterprise is needed to improve health care, but faces formidable challenges. To define the impediments and formulate solutions, the Institute of Medicine's Clinical Research Roundtable convened leaders from medical specialty and clinical research societies in 2003. Participants considered how to influence clinical research funding priorities, promote mechanisms to train physicians and other health care professionals to conduct clinical research, and how to encourage health care providers to follow evidence-based medical practice. Consensus emerged on multiple issues, including intersociety collaboration, the need for a core clinical research curriculum for training the new cadre of clinical researchers, joint advocacy for increased funding of clinical research and for the education of policymakers and the public on the benefits of clinical research. Specific recommendations were made on mechanisms for recruitment, training, and retention of clinical research trainees and mentors. Steps were outlined (1) to overcome career disincentives and develop appropriate reward systems for mentors and trainees, (2) to encourage use of web-based and continuing-medical-education-based mechanisms to bring practitioners up to date on issues in and results of clinical research, and (3) to create incentives for individuals, clinics, and hospitals to practice evidence-based medicine (EBM). Collectively, the response and proposed strategies can serve as a roadmap to improve clinical research funding and training, evidence-based medical practice, and health care quality.

Biomedical Research↗
PubMedDate not supplied

Modeling case mix adjustment of stroke rehabilitation outcomes.

Case mix adjustment models for long-term stroke rehabilitation outcomes should be developed (1) to facilitate equitable comparisons of outcomes across treatment settings, thereby reducing disincentives for treating complex cases, (2) to improve triage into the most appropriate level of rehabilitative care after discharge from acute care, and (3) to confirm that case mix factors are equated in treatment effectiveness studies and by random assignment across conditions in clinical trials. Case mix adjustment is necessary for valid quality improvement processes. A conceptual model of case mix adjustment of long-term rehabilitation outcomes is presented that (1) is diagnosis-specific, (2) includes demographic variables as important case mix factors, (3) encompasses triage into rehabilitation as well as treatment processes as aspects of quality of rehabilitative care, (4) contains outcomes measuring functional status as well as mortality and morbidity, and (5) keys timing of outcomes to onset of conditions requiring rehabilitation rather than discharge from rehabilitation. The number of potential interactions among case mix indicators requires a sophisticated analytic framework. Random factors in the model illustrate that case mix adjustment can never be perfect. Nevertheless, it is essential. A brief review of the stroke literature on prediction of long-term outcomes suggests that additional work is needed to specify relevant case mix indicators.

Activities of Daily Living↗
PubMedDate not supplied

Caregivers' attitudes toward their family members' participation in Alzheimer disease research: implications for recruitment and retention.

Current levels of participation in Alzheimer disease (AD) research are inadequate, particularly among nonwhites. This study was conducted to examine caregivers' attitudes toward their family members' participation in AD research. Six focus group interviews were conducted with 38 white and 12 African-American caregivers of participants enrolled in clinical research projects. Both white and African-American families participated in research to help their care recipients and future generations, receive support from the clinical and research staff, and obtain feedback about patient status and research results. Among white caregivers, primary barriers to participation in research included the potential for no direct benefit, problems with the procedures and tests involved, lack of time and resources, and difficulty accepting the diagnosis. Among African-American caregivers, primary barriers included general skepticism about the research process and firmly established attitudes about medical treatment and help seeking that serve as disincentives to research participation. To maximize the perceived benefits of research participation, potential participants should have access to regular personal contact with staff, information about health status changes in the care recipient, and the short-term and long-term results of the research studies in which they are participants. In addition, researchers should be sensitive to the concerns that may serve as barriers to participation, particularly among African Americans.

Adult↗
PubMed1997

Incentives to disability in federal disability insurance and supplemental security income.

Between 1989 and 1994, Disability Insurance and Supplemental Security Income, the 2 federal programs that provide disability benefits, expanded rapidly. The largest growth has been among recipients with mental disorders in the Disability Insurance program and among children with learning disabilities in the Supplemental Security Income program. The expansion was partly due to changes in eligibility rules and partly to other factors including outreach efforts by the Social Security Administration and a lack of funds to review and terminate cases. Factors that keep many of the disabled from seeking work include a fear of being unable to obtain health insurance, which is provided to beneficiaries under Disability Insurance and Social Security Insurance, and the fear of being unable to obtain and keep stable employment. Although children's Supplemental Security Income benefits have reduced poverty in families with disabled children, there is some evidence that parents are encouraging their children to behave poorly so they can qualify. Replacing present welfare and disability programs with national health insurance and a guaranteed annual income would eliminate the work disincentives, but such dramatic restructuring is unlikely in the context of present political debates.

Eligibility Determination↗
PubMed2002

Too many notes?

Orphan sources are now recognized as a radiation protection problem needing attention. Government and private sector initiatives have been mounted in response. Should more be done? There are promising possibilities. Under the ICRP 60 system of radiation protection, any use of radiation should be justified. Key NRC licensing regulations predate ICRP 60 and, consequently, if a use is authorized by license, then the use is presumed to be justified even if alternatives are available. As an example, x-ray gauges can be successfully substituted for nuclear container fill level gauges in the food and beverage industry. But this development is not widely known to potential users and regulators, and current regulatory policies do not address this. Limiting the number of radioactive devices would limit the number of potential orphan sources. From an operational radiation safety point of view, persons wanting to dispose of unneeded or unwanted radioactive sources are faced with a system loaded with disincentives, in part because disposition options are not well known and in part because options have become limited, complex, and expensive. New approaches are needed if the orphan source problem is to be effectively addressed. Paramount are the needs to (1) update U.S. regulatory policies to incorporate the ICRP principle of justification, (2) create a system that encourages prompt, safe dispositioning of unneeded and unwanted radioactive sources, and (3) make information on these points universally known to users of radioactive sources.

Humans↗
PubMed1989

Gastroenterology, diagnosis-related groups, and age.

Hospitals are now being reimbursed by a prospective Diagnosis-Related Group (DRG) classification system. There have been no major changes in the Federal Medicare DRG classification system since its inception 5 years ago. In this project, we analyzed all gastrointestinal (GI) medicine admissions by age and resource utilization at a large academic medical center. Total hospital costs for the 3,598 GI patients (January 1, 1985, through December 31, 1987) were $18,460,604. Although DRG reimbursement for all patients for the 3-year period would have generated an aggregate profit of $957,760, four out of five age categories of patients 65 years of age and above would have generated losses; the highest loss was for patients 85 years and over, at $2,235 per patient. Older GI patients (i.e., 65 years and over) had higher hospital costs, longer lengths of stay, more diagnoses and procedures per patient, and a higher mortality rate than younger patients. Both intensive care unit (ICU) and blood utilization rose with age. Thus, older GI patients consumed a disproportionately larger share of hospital resources. Our study suggests that the current DRG reimbursement scheme may be inequitable relative to the older GI medicine patient; financial disincentives from DRGs may affect elderly patients' access to and quality of care in the future.

Academic Medical Centers↗