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PubMed1989

Incidence, costs, and DRG-based reimbursement for traumatic brain injured patients: a 3-year experience.

A 3-year prospective study was conducted to establish the incidence of traumatic brain injury (TBI) and related characteristics of age, sex, length of stay (LOS), intensive care unit LOS (ICU/LOS), direct hospital charges, and reimbursement using a prospective DRG-based reimbursement system. The study identified TBI patients using ICD-9-Codes. The mean LOS for the two groups of patients with intracranial injury differed (p less than 0.05). Those with such an injury accompanied by a fracture stayed 1.8 days less in the ICU and 6.0 days less overall. Direct hospital charges for all TBI patients were $14,138,036 (mean, $11,645). Using Medicare weights and hospital-specific rates/DRG, the DRG reimbursement was $6,689,293. Thirty-day outliers (those who stayed ten times the geometric mean length of stay) provided an additional $526,389 leaving a total non-reimbursable figure of $6,922,354, or 49% of total charges. Of the 71 DRGs assigned to the study population, 15 reimbursed more than the actual charges. The severity of TBI victims and the complexity of caring for them in a Level I trauma center generates hospital charges of which only half are reimbursed through an all-payor DRG system. Strategies to correct what could be a financial disincentive are: documenting the uniqueness of this population to justify additional reimbursement, calculating a more precise mean LOS for TBI-related DRGs to more accurately identify outliers, and calculating DRG rates for TBI diagnoses derived from a representative sample at varying severity levels and hospitalized in facilities with and without rehabilitation services.

Adolescent↗
PubMed1994

A quantitative method for cost reimbursement and length of stay quality assurance in multiple trauma patients.

OBJECTIVE: To develop a statistically valid method for trauma reimbursement and quality assurance (QA) length-of-stay filters. This is needed because diagnosis related group (DRG)-based trauma payment systems assume a random sampling of injury severities from a normally distributed population and thus result in economic disincentives to level I trauma centers. METHODS: 142 trauma patients with MVC blunt multisystem injuries (MSI) (ISS > or = 16) were studied concurrently during their hospital course. SETTING: Level I regional trauma center. OUTCOME MEASURES: Outcome measures were (dependent variables) length of stay (LOS) and state-approved hospital charges (COST). RESULTS: Mean acute care COST was $74,310, but the distribution of COST was log normal, rather than Gaussian normal as assumed by DRGs. The LOS for MSI was more than twice the average for all trauma (22 vs. 9 days), reflecting skewed severities of level I patients and was related to COST (r2 = 0.802; p < 0.0001). The ISS alone was a weak determinant of COST or LOS (r2 = 0.05; p < 0.0001). The best single determinant of COST and LOS was survival (r2 = 0.15; p < 0.0001): as it increased, it increased LOS. The most costly injuries (all p < 0.0001) involved the lower extremity (LE) or hip joint (HIP), whereas sepsis and pulmonary and surgical complications constituted the most costly complications (all p < 0.0001). Regression models that accounted for the log-normal distribution of the dependent variable and based on binary variables for survival, LE and HIP injuries, and the complications of sepsis, ARDS, pulmonary failure, MOFS, plus ISS, explained nearly two thirds of the variability in COST (r2 = 0.621; p < 0.0001) or LOS (r2 = 0.687; p < 0.0001) and the residuals were normally distributed. CONCLUSIONS: These models provide a valid method of reimbursement for MSI trauma for level I trauma centers, since the data imply that good care associated with survival from specific complications of MSI are the major determinants of COST, rather than the specific type of injury or the resultant ISS. Moreover, using survival and ISS plus the disease-related complications as determinants of LOS, this method can be applied to any U.S. region since local factors can be used to adjust hospital COST as a highly correlated function of LOS. This method also permits identification of LOS outliers for QA, taking into account the influence of injury complications.

Accidents, Traffic↗
PubMed1984

Office laboratory tests. Perceptions of profitability.

Theoretic modeling suggests that common office tests as a group are profitable. To determine whether practicing internists perceive this profitability and whether their perceptions differ for different tests or for patients with different types of insurance coverage, the authors surveyed 111 physicians in private office practice. Respondents' estimates of receipts for tests done on patients with Medicare or Blue Cross/Blue Shield coverage were higher than their estimated costs for the testing. Estimates of receipts from Medicaid patients were lower than estimated costs of testing. After standardizing the estimated receipts from patients with different insurance coverages, the authors found that the average estimated profits for different tests on an "average insured patient" varied sixfold, from $5.99 for an electrocardiogram to $1.01 for a urinalysis. The authors suggest that perceived financial incentives are extremely variable by test. Different insurance coverages are perceived as providing varying financial incentives for testing; Medicaid provides a disincentive. Appropriate reform of the existing fee schedules should be selective by test and coverage.

Attitude to Health↗
PubMed1986

DRGs and disease staging for reimbursing Medicare patients.

Beginning October 1, 1983, Medicare began reimbursing many hospitals on the basis of a set of fixed fees tied to Diagnosis-Related Groups (DRGs). Using 1979-1981 Maryland data for Medicare patients, this paper compares the DRG system with the Disease Staging patient classification system in terms of structure, explanation of resource consumption (length of stay) of hospital patients, and impact on reimbursement by type of hospital. The two systems are conceptually and empirically different in classifying patients. Further, Disease Staging and DRGs perform similarly in explaining length-of-stay variation among Maryland patients. However, the two systems generate substantially different reimbursements by type of hospital. Surprisingly, large hospitals (including urban, not-for-profit, teaching hospitals) fare better under a DRG-based reimbursement system than under Disease Staging, a severity-of-illness system that excludes procedures as a basis of classification. These results imply that reimbursement policy based on Disease Staging would create disincentives to perform surgery compared with the current DRGs.

Diagnosis-Related Groups↗
PubMed1992

Nursing home case-mix classification and residents suffering from cognitive impairment: RUG-II and cognition in the Texas case-mix data base.

Case-mix reimbursement systems for nursing home care are now in use or under consideration in over 20 states. Though many in the long-term care field still debate the relative merits of the various systems, those systems based on the Resource Utilization Groups-II (RUG-II) system used in New York seem to be increasingly popular. However, one of the more serious questions raised concerning RUG-like systems is whether they fully acknowledge the role played by cognitive deficits in determining nursing home residents' care needs. The results of this research indicate: 1) that resource provision and cognitive status are correlated, 2) that residents with higher levels of cognitive impairment appear most frequently in RUG-II categories that have higher case-mix weights, 3) that simply adding some measure of cognitive function does not significantly increase the power of these models, and 4) that the RUG-II model predicts the level of care resources provided to the cognitively intact much better than it predicts those provided to residents suffering from relatively severe disorientation. These results imply that such classification systems may create disincentives for the admission of the most cognitively impaired residents and that the care of these individuals, more than others, may be dependent on facility-to-facility variation.

Activities of Daily Living↗
PubMed1996

Impact of interhospital transfers on outcomes in an academic medical center. Implications for profiling hospital quality.

The purpose of this article is to determine whether a widely implement ed method of severity adjustment underestimated the risk of death and other outcomes among interhospital transfers (ie, patients transferred from other acute care hospitals) and to examine the impact of this potential bias on hospital outcomes profiles. The retrospective cohort study was conducted at a midwestern academic medical center with 40,820 adult medical and surgical patients from 1988 to 1991, of whom 38,946 were direct admissions and 1,874 were interhospital transfers. Hospital mortality, length of stay, and total charges in interhospital transfers and direct admissions were compared using multivariable regression methods that adjusted for admission severity of illness and other potential covariates (age, type of health insurance, diagnosis, emergent admission). Severity of illness was measured using the Medis-Groups methodology. Admission severity of illness was directly related (P<0.001) to rates of in-hospital death, length of stay, and charges, and was higher among interhospital transfers; 49% of transfers had moderate to high severity, compared with 35% of direct admissions (P<0.001) However, in a logistic regression model adjusting for severity and other covariates, the risk of in-hospital death was nearly two times (multivariable odds ratio, 1.99; 95% confidence interval [CI], 1.64-2.42) higher in transfers than in direct admissions. In linear regression models, length of stay and charges were 1.47 (95% CI, 1.42-1.53) and 1.40 (95% CI, 1.35-1.44) times higher, respectively, in transfers. Results were consistent in medical and surgical admissions, when examined separately, and among individual diagnostic categories. Based on their findings, the authors estimate that, independent of quality of care, severity adjusted mortality and length of stay would appear 17% and 8% higher, respectively, for hospitals in which 20% of patients were interhospital transfers than for hospitals in which 2% of patients were transfers. In an academic medical center, interhospital transfers had poorer severity adjusted outcomes than patients admitted directly. Failure to account for transfer status may produce biased performance profiles and, therefore, may create disincentives for hospitals to accept transfers from other acute care facilities.

Academic Medical Centers↗
PubMed1998

Determinants of home health visit length: results of a multisite prospective study.

OBJECTIVES: The authors (1) compare visit length across four categories of skilled nursing home health visits which reflect recent changes in home health casemix-AIDS-related, hospice/terminal (HT), intravenous (IV) therapy, and maternal and child health (MCH)-with general adult medical/surgical (MS) visits and (2) identify factors influencing visit length. METHODS: The study sites were 12 nonproprietary Massachusetts home health agencies (HHAs). Staff nurses collected data concurrently on a sample of visits they provided between December 1, 1992 and November 30, 1993. The visits were stratified by agency, time of year, and visit category. The authors used analysis of variance to test for significant differences across visit categories in Home Length of Visit (the number of minutes between when the nurse entered and left the home) (HLOV). The authors used multivariate regression analysis to develop models identifying determinants of HLOV and adjusted R2 to measure the explanatory power of partial models. RESULTS: In univariate analysis, the categories differed significantly from each other in length (P < 0.0001). HT visits were the longest (median visit length = 60, 80, and 59 minutes for HT Only visits, visits in both the HT and AIDS categories (HT/AIDS), and HT/IV visits, respectively). MS visits were the shortest (median = 30 minutes). The remaining categories were intermediate in length (medians = 37 to 50 minutes). Almost half the variability in HLOV was explained by the full multivariate regression model, which includes all independent variables (adjusted R2 = .4486; P < 0.0001). Visit characteristics alone in a partial model explained 18% of the variability in HLOV. Three other variable sub-groups-agency, client characteristics, and nursing workload-each explained about 15% of the variability in HLOV. Nursing activities performed during the visit explained 11%; several of these related to teaching, education, or assessment. CONCLUSIONS: Accurate reimbursement reflecting casemix differences is important to protect the teaching, education, and assessment functions of nurses; measure nurse productivity and allocate caseloads; maintain access to services for clients with greater needs; and avoid creating economic disincentives to the agencies that serve them. Payers formulating prospective payment systems can adjust per visit reimbursement rates to reflect differences in visit length by category and incorporate functional limitations, clinical instability, and case coordination as classification variables. Developers of home health casemix systems can use factor analysis to improve the robustness of multivariate models and include nursing workload in predicting visit length. Home health agencies measuring productivity and caseload across complex client populations can classify visits into three groups-MS; HT; and AIDS, IV, and MCH-or use the regression results to develop more refined predictors of visit length and nursing caseload.

Adult↗
PubMed2000

Patient satisfaction with hospital care: effects of demographic and institutional characteristics.

BACKGROUND: There are a growing number of efforts to compare the service quality of health care organizations on the basis of patient satisfaction data. Such efforts inevitably raise questions about the fairness of the comparisons. Fair comparisons presumably should not penalize (or reward) health care organizations for factors that influence satisfaction scores but are not within the control of managers or clinicians. On the basis of previous research, these factors might include the demographic characteristics of patients (eg, age) and the institutional characteristics (eg, size) of the health care organizations where care was received. OBJECTIVES: The goal of this study was to examine the extent to which a patient's satisfaction scores are related to both his/her demographic characteristics and the institutional characteristics of the health care organization where care was received. METHODS: We conducted an analysis of secondary data from the Veterans Health Administration (VHA), US Department of Veterans Affairs. The database contained patient responses to self-administered satisfaction questionnaires and information about demographic characteristics. Additional data from VHA were obtained regarding the institutional characteristics of the hospitals where patients received their care. RESULTS: Among demographic characteristics, age, health status, and race consistently had a statistically significant effect on satisfaction scores. Among the institutional characteristics, hospital size consistently had a significant effect on patient satisfaction scores. CONCLUSIONS: Study results can be interpreted as justifying the need to adjust patient satisfaction scores for differences in patient population among health care organizations. However, from a policy perspective, such adjustments may ultimately create a disincentive for health care organizations to customize their care.

Adult↗
PubMed1997

Laparoscopic assisted live donor nephrectomy--a comparison with the open approach.

Live donor renal transplantation provides significant advantages when compared with cadaveric donor renal transplantation in terms of improved patient and graft survival, a lower incidence of delayed function, and a shorter waiting time. Yet despite these advantages, live donors continue to be an under utilized source of kidneys for transplantation. Disincentives to live donation include the length of hospitalization, postoperative pain, cosmetic concerns, and the prolonged convalescence associated with the donor operation. In many instances minimally invasive video-assisted techniques have proven more efficacious than standard open procedures in terms of patient discomfort, length of hospital stay, cost, and length of time until the patient can return to full activity. Laparoscopic live donor nephrectomies are being performed at our institution in an attempt to make live donation more attractive to the potential donor. The purpose of this study was to retrospectively review the results of laparoscopic live donor nephrectomy (LapNx) and to compare them with those obtained using the standard open approach (OpenNx). Ten consecutive LapNx were performed from February 1995 through April 1996. The control group consisted of the 20 consecutive OpenNx performed at the same institution from January 1991 through January 1995 immediately before the initiation of the LapNx program. Live donors were considered candidates for LapNx if they possessed at least one kidney with normal renal anatomy with single renal vessels and a single ureter. LapNx was safely performed in all cases. No patients required open conversion or blood transfusions. The allograft warm ischemic time for the laparoscopic cases was 4.2+/-1.3 min. All kidneys harvested laparoscopically produced urine on the table immediately upon revascularization. Presently nine of the ten recipients have functioning allografts. At three months posttransplant the calculated recipient creatinine clearances were 67.0+/-11.5 ml/min and 64.8+/-21.4 ml/min for the LapNx and OpenNx groups, respectively (P=NS). The LapNx donors had a significantly decreased estimated blood loss, shorter time until resumption of oral intake, decreased postoperative pain (in terms of decreased analgesic requirements), shorter hospitalization, and a shorter interval until the resumption of full activities (P<0.05 for all). In addition, the LapNx group donors returned to work sooner than the OpenNx group (3.9+/-1.6 wk vs. 6.4+/-3.1 wk, respectively) (P=0.024). Four individuals agreed to donate a kidney only after learning of the availability of the laparoscopic approach. We conclude that laparoscopic live donor nephrectomy is technically feasible. In addition, it may offer significant advantages over the standard open approach in terms of patient comfort and convenience. These advantages may make live donor renal transplantation more attractive to prospective donors. The potential decrease in hospitalization and convalescence may also prove to be financially advantageous. We believe that further careful study of this procedure is warranted.

Adult↗
PubMed2001

A survey: the prevalence of laparoscopic donor nephrectomy at large U.S. transplant centers.

BACKGROUND: There is controversy whether laparoscopic donor nephrectomy (LDN) is the procedure of choice for live kidney donors. The purpose of this survey therefore was to determine the current practices, attitudes, and plans regarding LDN in high-volume renal transplant centers. METHODS: Medical directors of the 31 highest volume kidney transplant centers were surveyed via telephone. Kidney transplant data for 1998 and 1999 were collected. RESULTS: The surveyed centers performed 5213 transplantations in 1998, representing 43% of all kidney transplantations done nationally. Twelve (39%) of the 31 centers performed LDN in 1998, increasing to 20 (65%) of 31 in 1999. Of 1174 live donor operations performed by the 20 centers in 1999, 365 (31%) were LDNs. Among the surveyed centers, four had no plans to begin an LDN program. The most commonly cited incentive for LDN was "shorter recovery time," whereas the most common disincentive was "concern about graft quality." A combination of observation and animate laboratory was the most commonly reported method of learning the LDN procedure. Six-month follow-up interviews found that 26 (84%) of 31 centers had performed LDN; only 1 of the 31 centers had no plans to perform LDNs. CONCLUSIONS: LDN may be the de facto procedure of choice for live donors within the next year. Efforts should now focus on improving techniques for performing and teaching this procedure.

Data Collection↗
PubMed2001

Interaortocaval renal artery dissection for right laparoscopic donor nephrectomy.

Laparoscopic donor nephrectomy is gaining increasing popularity because the procedure helps reduce disincentives to live kidney donation and has increased the live kidney donor pool. The left kidney of the donor is the preferred allograft because the right renal vein is shorter. Similarly, the right renal artery might be foreshortened because it hides behind the inferior vena cava during laparoscopic transperitoneal dissection. There are instances, however, in which it is not practical to take the left kidney due to vascular anomalies or asymmetric function. We describe a novel technique for obtaining greater renal arterial length utilizing laparoscopic interaortocaval dissection.

Aorta↗
PubMed2001

Laparoscopic donor nephrectomy: an update.

Laparoscopic donor nephrectomy was developed primarily to increase the number of kidneys available for donation. Further evidence of the safety and efficacy of laparoscopic donor nephrectomy has been reported in the literature, as have studies on the cost-effectiveness of this procedure and its role in removing disincentives for renal donation. Specific technical modifications have been developed and refined that improve outcomes when performing laparoscopic harvesting of right kidneys. Other technical modifications have been developed for use in obese patients. With the adoption of these modified techniques, equivalent results to open donor nephrectomy have been reported. Recently, a wide range of alternative approaches (hand-assisted, retroperitoneal, and gasless laparoscopy) have been utilized for laparoscopic donor nephrectomy.

Cost-Benefit Analysis↗
PubMed1999

Laparoscopic donor nephrectomy: standard of care or unnecessary risk of organ loss?

Laparoscopic donor nephrectomy was developed to remove disincentives to live donation. It has been demonstrated to decrease the length of hospitalization, postoperative pain, time to convalescence and activity, while providing an optimal cosmetic result. Initial reports suggest that laparoscopic donor nephrectomy is feasible and equivalent to open donor nephrectomy.

Humans↗
PubMed1990

Occupational bladder cancer in textile dyeing and printing workers: six cases and their significance for screening programs.

Occupational bladder cancer due to aniline dye intermediates such as beta-naphthylamine and benzidine has long been known; benzidine congeners (o-tolidine and o-dianisidine) are highly suspect. Among 400 men from the Amalgamated Clothing and Textile Workers Union (ACTWU) Dyers locals in New York and New Jersey screened over a 4-year period, two cases of bladder cancer were detected. (Microscopic hematuria, not cytological evaluation, prompted further investigation.) Before a 1984 ACTWU screening program in North Carolina, three workers from the same plant self-reported bladder cancers. Another member, with inconclusive screening results, was diagnosed 2 years later. For these six cases, the mean age at detection was 56.5 years (age range, 38 to 79 years), a decade earlier than age at diagnosis of nonoccupational bladder cancer in men. The average latency from onset of exposure to diagnosis was 23.3 years. These cancers provide evidence to support the initiation of screening programs for high-risk workers. To overcome the emotional and economic disincentives faced by potential victims of occupational bladder cancer, training programs are needed. Worker involvement is required, through trade union representation where possible, to assure reliable training and the equitable distribution of screening and treatment costs.

Adult↗
PubMedDate not supplied

Heart failure disease management: implementation and outcomes.

Millions of dollars are being spent to identify new therapies to improve mortality and morbidity for the growing epidemic of patients sustaining heart failure. However, in clinical practice, these therapies are currently underused. To bridge the gap between proven therapies and clinical practice, the medical community has turned to disease management. Heart failure disease management interventions vary from vital-sign monitoring to multidisciplinary approaches involving a pharmacist, nutritionist, nurse practitioner, and physician. This review attempts to categorize these inventions based on location. We compared the published results from randomized, controlled trials of the following types of heart failure disease management interventions: inpatient, clinic visits, home visits, and telephone follow up. Although research shows an improvement in the quality of care and a decrease in hospitalizations for patients sustaining heart failure, the economic impact of disease management is still unclear. The current reimbursement structure is a disincentive to providers wanting to offer disease management services to patients sustaining heart failure. Additionally, the cost of providing disease management services such as additional clinical visits, patient education materials, or additional personnel time has not been well documented. Most heart failure disease management studies do confirm the concept that providing increased access to healthcare providers for an at-risk group of patients sustaining heart failure does improve outcomes. However, a large-scale randomized, controlled clinical trial based in the United States is needed to prove that this concept can be implemented beyond a single center and to determine how much it will cost patients, providers, healthcare systems, and payers.

Aged↗
PubMed2004

Urodynamic and immunohistochemical evaluation of intravesical capsaicin delivery using thermosensitive hydrogel and liposomes.

PURPOSE: Aqueous insolubility of the vanilloids such as capsaicin is a major disincentive in their intravesical therapy of detrusor hyperreflexia. We sought to overcome the delivery of this hydrophobic neurotoxin by entrapping it in a lipid bilayer of positively charged multilamellar lipid vesicles (liposomes) or in a hydrophobic polymer matrix of thermosensitive hydrogel. MATERIALS AND METHODS: Liposomes, hydrogel and 30% ethanol/normal saline were prepared with or without 1 mM capsaicin (0.5 ml) and administered intravesically for 30 minutes to 7 groups of age matched, normal female adult Sprague-Dawley rats under halothane anesthesia. At 48 hours after intravesical instillation cystometric studies were performed using urethane anesthesia (0.04 ml per minute). The animals were subsequently sacrificed and whole bladders were harvested for histology and immunohistochemistry. RESULTS: In normal urethane anaesthetized rats capsaicin in 30% ethanol and liposomes completely blocked micturition reflexes. Capsaicin in hydrogel did not completely block the micturition reflex but it significantly decreased bladder contraction frequency compared with vehicle controls. The results of cystometry with capsaicin in liposomes and capsaicin in 30% ethanol correlated with a significant decrease in calcitonin gene-related peptide staining of afferent nerves in the bladder wall. Photographs taken after hematoxylin and eosin staining of the bladder treated with liposomes and hydrogel in the absence of capsaicin did not reveal any adverse histological changes. There were significant histological changes in bladders treated with 30% ethanol alone. CONCLUSIONS: In comparison with 30% ethanol liposomes are a superior vehicle for the intravesical administration of capsaicin, producing comparable efficacy with less tissue damage. Hydrogel can also serve as safe alternative option for capsaicin delivery.

Administration, Intravesical↗
PubMed2006

The shape of things to come: results from a national survey of trauma surgeons on issues concerning their future.

BACKGROUND: This study seeks to characterize the opinions of practicing surgeons as a basis for formulating a plan to restructure the discipline of trauma surgery and its training path. METHODS: A 52-item questionnaire was administered to the membership of the American Association for the Surgery of Trauma, the Eastern Association for the Surgery of Trauma, and the Western Trauma Association. The survey tool investigated issues related to current and future practice. RESULTS: Response rate was 60%. Mean age was 49 years and 88% were male. The average time in practice is 15 years. The average workweek is 80 hours with 48% of that time devoted to clinical practice. About half take in-house call and about one-third receive an on-call stipend. The median annual number of major trauma cases was 50. The most important disincentives to entering the field were felt to be lifestyle issues and a limited scope of practice. Almost 90% felt their work as trauma surgeons was undervalued by society and the health care system. The great majority (88%) responded that the discipline of trauma surgery must change. Respondents feel this restructuring should include broader general surgery (83%) as well as limited orthopedic (60%) and neurosurgical trauma-related procedures (59%). About one-half of respondents favored in-house call (54%) and a practice model similar to emergency medicine (55%). Factors that would most enhance practice were thought to be guaranteed appropriate salary and guaranteed time away from work. Training in a broad range of skills was felt to be essential or useful to the trauma surgeon of the future, although few currently employ such a wide breadth of skills. CONCLUSIONS: Current practicing trauma surgeons feel that the discipline must change to remain viable. This change should entail broader training to allow more procedures in trauma, emergency surgery, critical care, and elective general surgery. The preferred practice model is a large, hospital-based, diversified group practice with a predictable lifestyle and guaranteed salary commensurate with effort. Inclusion of selected emergency orthopedic and neurosurgical procedures are viewed favorably, as is in-house call. Efforts to increase public perception of trauma surgery's value to society and its impending demise are warranted.

Attitude of Health Personnel↗
PubMed2006

Mental illness and employment discrimination.

PURPOSE OF REVIEW: Work is a major determinant of mental health and a socially integrating force. To be excluded from the workforce creates material deprivation, erodes self-confidence, creates a sense of isolation and marginalization and is a key risk factor for mental disability. This review summarizes recent evidence pertaining to employment-related stigma and discrimination experienced by people with mental disabilities. A broad understanding of the stigmatization process is adopted, which includes cognitive, attitudinal, behavioural and structural disadvantages. RECENT FINDINGS: Stigma is both a proximate and a distal cause of employment inequity for people with a mental disability who experience direct discrimination because of prejudicial attitudes from employers and workmates and indirect discrimination owing to historical patterns of disadvantage, structural disincentives against competitive employment and generalized policy neglect. Against this background, modern mental health rehabilitation models and legislative philosophies, which focus on citizenship rights and full social participation, are to be welcomed. Yet, recent findings demonstrate that the legislation remains vulnerable to the very prejudicial attitudes they are intended to abate. SUMMARY: Research conducted during the past year continues to highlight multiple attitudinal and structural barriers that prevent people with mental disabilities from becoming active participants in the competitive labour market.

Employment↗