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PubMed2002

Extending life: scientific prospects and political obstacles.

Aging can be slowed in laboratory rodents by low-calorie diets, and changes in single genes can extend mouse life span by 40 percent or more. Therefore, despite its surface complexity and effects on multiple cells and intercellular systems, aging in mammals might also be retarded by both genetic and nongenetic means. If human aging could be slowed pharmacologically to the extent now possible in rodents, the effect on healthy life expectancy would exceed that of abolishing cancer, cardiovascular disease, and adult-onset diabetes. Why, then, is research on the biological control of aging and longevity poorly funded and shunned by both most scientists and those setting national research priorities? Economic disincentives, disease-specific lobby groups, scientific careerism, and ineffective nostrums, together with gerontologiphobia, must be overcome before such research can improve public health.

Aged↗
PubMed1991

General practitioners' experiences of patients with drug and alcohol problems.

Convergent focus groups, a qualitative research methodology, were used to determine what general practitioners considered to be the main obstacles and disincentives to the effective management of persons with drug and alcohol problems. Seven groups were conducted, involving 44 general practitioners whose practices were based in representative parts of metropolitan Sydney and a rural area of New South Wales. The study revealed that most doctors are not as threatened, resistant or pessimistic about drug and alcohol intervention as much of the previous work in the area would suggest. However, they held different views according to the drug in question. General practitioners were more sympathetic to patients with alcohol problems but only some agreed that it was a legitimate area for medical involvement and one in which they were prepared to become involved. The prescribing and use of minor tranquillisers was widely tolerated and perceived to present few problems for individuals or the community. Opiate users, by contrast, were least favoured, with hostility expressed by most towards them. A provisional typology of general practitioners was developed with three distinct groupings ('interactive problem-solvers', 'traditionalist healers' and 'technologists'), according to the model of medical practice assumed. This scheme, whilst not definitive, provides a structure for targeting general practitioners for medical education and has implications for tailoring medical training programs at both the undergraduate and postgraduate levels. General issues relating to the development of typologies are discussed.

Adult↗
PubMed2005

Chylous ascites as a complication of laparoscopic donor nephrectomy.

Laparoscopic living donor nephrectomy (LLDN) is a minimally invasive technique for kidney procurement and was developed with the hope of reducing the disincentives associated with live renal donation. Compared with open donor nephrectomy (ODN), this alternative has many advantages including less postoperative pain and earlier return to work. Unfortunately, these benefits are sometimes negated by postoperative complications. Among these, chylous ascites (CA) is a rare but serious problem that is usually managed conservatively. We report the case of a living donor who developed CA refractory to initial conservative management and surgical treatment. We also discuss the role of surgery in the treatment of CA following LLDN.

Chylous Ascites↗
PubMed1993

Early thrombolytic treatment in acute coronary thrombosis.

It is now accepted that the earliest event in acute myocardial infarction is coronary occlusion caused by fissuring of an atherosclerotic plaque, with resultant platelet deposition on the mural flaw and build up of thrombus within the lumen. The symptoms generated are caused by myocardial ischaemia, as first described by Herrick and Levine some 80 years ago. If occlusion is not relieved, irreversible damage (infarction) begins in the ischaemic region within 30 minutes, is half completed by 2.5 hours, and is virtually completed by six hours. Thrombolysis is now accepted therapy for acute evolving myocardial infarction, but in most cases such therapy is not commenced for four hours after symptom onset, when most of the irreparable damage has already been done and when the potential for benefit has fallen substantially. The average time to thrombolysis in GUSTO worldwide, however, was two hours and, in Australia, 2.8 hours. Only patients who could be submitted to thrombolysis within six hours of the onset of pain were included. The results of thrombolytic therapy in acute thrombosis are likely to be improved if delays are minimised. This requires education of the public in the symptoms of this condition, and on the actions to take if such symptoms arise. It also requires expeditious transfer to hospital (or appropriate treatment outside) and above all it requires expeditious assessment and treatment when patients arrive in hospital. Use of the diagnosis 'myocardial infarction' for such patients implies that irreversible damage has already occurred and serves as a disincentive for the speedy, aggressive management that is logical and appropriate for dissolution of the offending coronary thrombus.

Acute Disease↗
PubMed1997

Aren't health services already promoting health?

Smoke-free health care environments are now the norm in Australia and exemplify the way in which environments for health care can become more health promoting. Community health services that assist people with chronic illnesses and disabilities to increase control over their lives, hospitals that provide nutritious food choices for staff and patients, and general practices that encourage routine preventive care throughout the life span are other examples of health-promoting environments. In their roles as providers of services, employers, community corporations and citizens, health care organisations have a wide range of opportunities for developing their capacity for health promotion. These include transforming the principles and values on which service delivery models are based, developing an organisational capacity for health promotion through staff training and designing programs, services and facilities to promote health. While some industry accreditation programs are evolving to embody specific elements that are health promoting, significant barriers to this area of organisational development continue to exist. These include disincentives linked with health care financing and the values, priorities and skills of health care workers who must turn rhetoric into practice. Just as the introduction of smoke-free environments success on research findings and a supportive political and social milieu to be successful, the further development of environments for health care which are health promoting in other ways will need to be driven by evidence and advocacy.

Australia↗
PubMed2005

Are patients' decisions to refuse treatment binding on health care professionals?

When patients refuse to receive medical treatment, the consequences of honouring their decisions can be tragic. This is no less true of patients who autonomously decide to refuse treatment. I distinguish three possible implications of these autonomous decisions. According to the Permissibility Claim, such a decision implies that it is permissible for the patient who has made the autonomous decision to forego medical treatment. According to the Anti-Paternalism Claim, it follows that health-care professionals are not morally permitted to treat that patient. According to the Binding Claim it follows that these decisions are binding on health-care professionals. My focus is the last claim. After arguing that it is importantly different from each of the first two claims, I give two arguments to show that it is false. One argument against the Binding Claim draws a comparison with cases in which patients autonomously choose perilous positive treatments. The other argument appeals to considered judgments about cases in which disincentives are used to deter patients from refusing sound treatments.

Beneficence↗
PubMed1996

How many nonmelanoma skin cancers require Mohs micrographic surgery?

BACKGROUND: Cost containment in health care is currently a subject of much debate. The rapid spread of managed care is an attempt to influence practice trends and contain costs. Although seldom directly stated, it is implied that some physicians may perform high-cost procedures when not necessarily indicated, an example being Mohs micrographic surgery (MMS). OBJECTIVE: There are little data in the literature indicating what percentage of skin cancers treated by MMS would be appropriate. For such data to be meaningful, a model would have to exist wherein there is no financial incentive or disincentive for performing the procedure. Military medicine provides this unique environment. METHODS: In a retrospective review, we counted the total number of basal cell carcinomas and squamous cell carcinomas diagnosed at Brooke Army Medical Center (BAMC) over a 5-year period. We then determined the number of MMS cases performed on these cancers. RESULTS: A total of 5193 nonmelanoma skin cancers (NMSC) were diagnosed at BAMC and 1701 of these were treated by MMS. Overall, the percentage of NMSC treated by MMS was 32.7% for the 5-year period. CONCLUSION: This information may serve as a framework for physicians and health delivery systems as they negotiate managed care contracts for the management of skin cancer.

Basal Cell Carcinoma↗
PubMed1987

State initiatives in geriatric education.

Although the basic requisites of curricula in geriatrics and gerontology have been well developed, and the need for such programs is well established, the support for development of geriatric academic programs has not been commensurate with the need. Barriers to the development of such programs include ageism, financial disincentives, scientific underdevelopment, a dearth of trained faculty, the lack of institutional support, and the declining federal role. One attempt to overcome these barriers and address the tremendous need is the development of state initiatives. In the last decade, several state legislatures have begun to provide support for geriatric education. The purpose of this paper is to analyze the initiatives of state funded university programs in geriatrics and gerontology, with particular emphasis on the California experience. A survey involving 50 states was conducted using two rounds of structured telephone interviews. The survey results found that 44 states did not have any legislatively initiated support for geriatric programs in higher education. Six states did have such programs, they included: Ohio, North Carolina, Kansas, New York, Kentucky, and California. The components of the California program are discussed in further detail. The conclusions were that although these states provide paradigms for the rest of the nation, much more still needs to be done. Several issues raised by the state programs are discussed.

Data Collection↗
PubMed2004

Plasmapheresis, CMV hyperimmune globulin, and anti-CD20 allow ABO-incompatible renal transplantation without splenectomy.

The majority of preconditioning protocols developed to allow ABO-incompatible (ABOi) renal transplantation include concurrent splenectomy as a prerequisite to successful engraftment. Our center has developed a preconditioning protocol that includes plasmapheresis (PP), low-dose CMV hyperimmune globulin (CMVIg), and anti-CD20 monoclonal antibody (rituximab) to allow ABOi renal transplantation without splenectomy. Our initial experience has included treatment of six recipients and successful transplantation from blood group A(1), A(2), and group B living donors. Mean (+/- SD) serum creatinine was 1.3 +/- 0.1 mg/dL among the six recipients and no episodes of antibody-mediated rejection (AMR) occurred at a median follow-up of 12 months. ABO antibody titers have remained below pretreatment levels. The absence of AMR and stable allograft function in this series show the potential of this preconditioning protocol to increase ABOi renal transplantation. The use of rituximab, allowing avoidance of splenectomy, may further remove one of the significant disincentives to ABOi transplantation, and eliminate the risk of post-splenectomy infections.

ABO Blood-Group System↗
PubMed2005

ABO incompatible high-titer renal transplantation without splenectomy or anti-CD20 treatment.

Most successful protocols for renal transplantation across ABO incompatible (ABOi) barriers have utilized splenectomy as part of the pre-conditioning process. We recently described successful ABOi transplantation using anti-CD20 monoclonal antibody in lieu of splenectomy. In the current study, we hypothesized that plasmapheresis (PP) and low dose CMV hyper-immunoglobulin (CMVIg) alone would be sufficient to achieve successful engraftment of ABOi kidneys. We describe four blood type incompatible patients who received live donor renal transplants from A1 (two patients), A2 (one patient), and B (one patient) donors. All patients started with antihuman globulin (AHG) phase titers of 64 or higher and were pre-conditioned with PP/CMVIg but not splenectomy or anti-CD20. All 4 patients underwent successful transplantation and have a mean current serum creatinine of 1.1 (range: 0.9-1.2). There were no episodes of antibody mediated rejection. Rapid allograft accommodation may limit the need for long-term antibody suppression provided by splenectomy or anti-CD20, thereby eliminating the added infectious risk of these modalities and removing another disincentive to ABOi transplantation.

ABO Blood-Group System↗
PubMed1998

The new child health insurance expansions: how will school-based health centers fit in?

In June 1998, the Making the Grade National Program Office and the National Assembly on School-Based Health Care sponsored a workshop on the relationship between the State Child Health Insurance Program (SCHIP) and school-based health centers. Workshop participants used the health centers' experience with Medicaid managed care as a window for understanding their prospects for negotiating contracts with health plans under SCHIP. Speakers representing the federal perspective, state agencies, health plans, and local school-based health centers offered their views on the challenges of developing contracts, incentives, and disincentives that health plans have to contract with school-based health centers, and what has accounted for success where relationships are moving forward. Experiences in Colorado and Connecticut were presented as case studies on these evolving issues.

Child↗
PubMed1991

Health care in Canada: lessons for the United States.

This paper considers various aspects of the Canadian health care system and the implications for the improved delivery of rural health care in the United States. The major aspects examined are access to care, rural hospitals, and rural physicians. A search of the pertinent literature revealed a large amount of information concerning rural physicians in Canada, but less that dealt directly with rural hospitals and access to health care in rural areas. Universal access is the cornerstone of the Canadian health care system, which is operated by each province under certain mandates of the federal government, with both providing funding for the system. The diffusion of medical technology has been slower in Canada than in the United States, which is perceived by some as a major success of the system. Little distinction is made between rural and urban hospitals in Canada, with all hospitals funded by annual global budgets from the province, rather than by direct payment for each service provided. Funding for capital items must be requested separately. This method of reimbursement allows better planning in meeting the needs of each community. Physicians in Canada are mostly private practitioners who are reimbursed by fee for service. As in the United States, there has been difficulty in attracting physicians to rural areas. However, all but one province have incentive programs to encourage physicians to practice in underserved rural areas, with some having disincentives for those locating in overserved areas. Overall, the Canadian health care system has chosen to control costs by focusing on the provider rather than the consumer and appears to be more successful in providing access to health care in rural areas of the country.

Canada↗
PubMedDate not supplied

A survey of the availability of dental services to developmentally disabled persons residing in the community.

Public Law 88-164, enacted in 1963, has led to extensive deinstitutionalization of persons with mental retardation from a peak census of 194,650 in 1967 to 91,440 by 1988. This population now depends on the community-based health care system for medical and dental care. A survey conducted to determine the availability of dental care to the developmentally disabled residing in group homes located in north central Florida indicated that 40% of caretakers experienced difficulty in locating dentists willing to provide comprehensive dental services for residents. According to the caretakers, although 75% of the residents were cooperative dental patients, dentists were reluctant to provide services for a variety of reasons, including financial disincentives, inadequate knowledge and preparation, and a lack of proper equipment necessary to treat this group of special patients.

Adolescent↗
PubMed1978

Evaluation of medical practices.

Evaluation of the efficacy of a medical intervention requires valid measurements of both its benefits and risks as compared to those of alternative forms of management. The requisite measurements are more difficult to make than this simple description suggests, and the accumulation of information is further inhibited by certain characteristics of our pattern of health care. These features include, for example, discontinuous care by a variety of unrelated providers, inadequate records, the autonomy of physicians as decision-makers, financial disincentives, ambiguities in what we mean by "experimental" and "accepted" forms of therapy, and failure to see continuing evaluation as a necessary component of the cost of providing good medical care. Although no single change will solve all the problems of evaluation, several offer promise of improving our ability to choose from among medical interventions those most likely to be useful.

Cost-Benefit Analysis↗
PubMed1989

High and low incomes in general practice.

The Review Body on Doctors' and Dentists' Remuneration deals with average incomes and costs, and little evidence is available on local variability. In a study on general practice the distribution of high and low incomes was assessed. High income practices (defined as those with net incomes per partner of more than 35,000 pounds a year) were more likely to be larger, to have younger partners, and to be located in affluent areas. Low income practices (with a net income of less than 20,000 pounds per partner) were smaller, located in more urban areas, and more likely to have Asian partners. High income practices had higher costs per patient and more staff resources. Low income practices had fewer practice resources and faced great disincentives to investment. These practices were concentrated in less affluent areas, where the need for improved organisation of practices is greatest. General practice is becoming increasingly divided between high income, high cost practices and those with low incomes and few resources.

England↗
PubMed1995

OxDONS syndrome: the inevitable disease of the NHS reforms.

The financial demise of Oxford's department of neurosurgery (OxDONS) was precipitated by the financial rules of the reformed NHS. In particular it was produced by the failure of "resources to follow patients"; the requirement that "prices have to follow costs"; and the use of private income for revenue expenditure, not capital expenditure. This process will eventually affect all hospital departments, but it affected the unit in Oxford sooner as it started as "efficient"--that is, underresourced--and has depended on income from extracontractual referrals and private work. Current NHS accounting rules act as a disincentive to private income being generated in NHS hospitals, and consultants should be aware of this.

England↗
PubMed2000

NHSnet in Scottish primary care: lessons for the future.

OBJECTIVE: To evaluate the primary care communications initiative, which introduced NHSnet to primary care in Scotland. DESIGN: Semi-structured telephone interviews, postal questionnaire. SETTING: All 15 Scottish health boards, random sample of 1 in 3 of all Scottish general practices. PARTICIPANTS: Information management and technology managers of health boards, 355 practice managers in the general practices. MAIN OUTCOME MEASURES: Variations between health boards in styles of project management, means of connection to NHSnet, costs to general practices, and training provided. Practices' levels of participation in initiative, initial use of NHSnet, and factors acting as incentives and disincentives to use of NHSnet. RESULTS: 99% of Scottish general practices agreed to participate in initiative. Health boards varied significantly in project management styles (from minimal to total control), the nature of the networks they established (intranets or direct connections), costs to practices (from nothing to pound125 per general practitioner per year), and training provided (from none to an extensive programme). In 56% of practices someone accessed NHSnet at least once a week. Practices varied considerably in amount of internet training received and staff groups targeted and in the intention to provide desktop access to NHSnet through a practice network. CONCLUSION: The initiative has successfully introduced a network that links Scottish general practices, health boards, and hospital trusts. However local variation in this "national" initiative may affect its use in primary care. Health authorities and general practices in England and Wales may wish to note these findings in order to avoid unhelpful variation.

Computer Communication Networks↗
PubMedDate not supplied

Reducing the frequency of errors in medicine using information technology.

BACKGROUND: Increasing data suggest that error in medicine is frequent and results in substantial harm. The recent Institute of Medicine report (LT Kohn, JM Corrigan, MS Donaldson, eds: To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press, 1999) described the magnitude of the problem, and the public interest in this issue, which was already large, has grown. GOAL: The goal of this white paper is to describe how the frequency and consequences of errors in medical care can be reduced (although in some instances they are potentiated) by the use of information technology in the provision of care, and to make general and specific recommendations regarding error reduction through the use of information technology. RESULTS: General recommendations are to implement clinical decision support judiciously; to consider consequent actions when designing systems; to test existing systems to ensure they actually catch errors that injure patients; to promote adoption of standards for data and systems; to develop systems that communicate with each other; to use systems in new ways; to measure and prevent adverse consequences; to make existing quality structures meaningful; and to improve regulation and remove disincentives for vendors to provide clinical decision support. Specific recommendations are to implement provider order entry systems, especially computerized prescribing; to implement bar-coding for medications, blood, devices, and patients; and to utilize modern electronic systems to communicate key pieces of asynchronous data such as markedly abnormal laboratory values. CONCLUSIONS: Appropriate increases in the use of information technology in health care- especially the introduction of clinical decision support and better linkages in and among systems, resulting in process simplification-could result in substantial improvement in patient safety.

Decision Support Systems, Clinical↗