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PubMed2006

Multidrug-resistant tuberculosis management in resource-limited settings.

Evidence of successful management of multidrug-resistant tuberculosis (MDRTB) is mainly generated from referral hospitals in high-income countries. We evaluate the management of MDRTB in 5 resource-limited countries: Estonia, Latvia, Peru, the Philippines, and the Russian Federation. All projects were approved by the Green Light Committee for access to quality-assured second-line drugs provided at reduced price for MDRTB management. Of 1047 MDRTB patients evaluated, 119 (11%) were new, and 928 (89%) had received treatment previously. More than 50% of previously treated patients had received both first- and second-line drugs, and 65% of all patients had infections that were resistant to both first- and second-line drugs. Treatment was successful in 70% of all patients, but success rate was higher among new (77%) than among previously treated patients (69%). In resource-limited settings, treatment of MDRTB provided through, or in collaboration with, national TB programs can yield results similar to those from wealthier settings.

Antitubercular Agents↗

PubMed1998

Discounting costs and effects: a reconsideration.

Using a simple societal utility function--giving equal weight to current and future generations-it is concluded that costs need to be discounted on the basis of the expected increase in income and the marginal utility of consumption, and that effects need to be discounted on the basis of the expected increase in health and the marginal utility of health. It is derived that both rates need to be equal when assuming a kind of perfect market, where growth rates are determined by the societal utility function. It is argued that this is an extremely heroic assumption and that different discount rates may be needed. Additionally, the traditional 'inconsistency arguments' of Weinstein and Stason and of Keeler and Cretin are reconsidered. Within the context presented earlier, the first inconsistency only emerges when a growth equilibrium is assumed, reinforcing the arguments put forward before. The Keeler and Cretin paradox is reconsidered by showing that absolutely no paradox emerges when programs are not supposed to stop after a year but are supposed to continue indefinitely. The conclusion is drawn that non-believers in market mechanisms assuring an optimal social policy, need to reconsider the use of their discount rates.

Cost-Benefit Analysis↗

PubMed1992

Evaluation of social problem-solving abilities in rural home health visitors and visiting nurses.

A number of studies have shown the value of using home health visitors and visiting nurses in intervention outreach programs designed to provide pre- and postnatal care for low-income women. The purpose of this study was to compare the abilities of a selected sample of professionally trained nurses and nonprofessionally trained home health visitors to suggest and prioritize solutions to a medical dilemma. Data were gathered by the use of a Practical Solutions Test and a Ranking Solutions Procedure. The subjects for the study were 77 females residing in rural counties in West Alabama. The four study groups were comprised of: (a) trained home visitors with 0 to 6 months of experience, (b) trained home visitors with more than 6 months of experience, (c) professionally trained nurses, and, (d) a control group of women with no training or experience. Data were analyzed using one-way analysis of variance (ANOVA). The findings suggest that all of the trained groups were able to generate more solutions to a typical client medical dilemma than could the control group: F(3.76) = 11.79; p = .0001. Faced with the same medical dilemma, the nursing group was more likely to suggest medical options over socioemotional solutions than were the home visitors: chi 2(3.76) = 9.41; p = .02. The nurses also prioritized the solutions differently by ranking them in a different sequence.

Adult↗

PubMed2001

Unlocking specialists' attitudes toward primary care gatekeepers.

OBJECTIVES: Many managed care plans rely on primary care physicians to act as gatekeepers, which may increase tension between these physicians and specialists. We surveyed specialist physicians in California to determine whether their attitudes toward primary care gatekeepers differed depending on how the specialists were paid and the settings in which they practiced. STUDY DESIGN: We performed a cross-sectional survey using a mailed questionnaire. The predictors of specialist attitudes toward gatekeepers were measured using chi-square, the t test, and regression analyses. POPULATION: A probability sample of 1492 physicians in urban counties in California in the specialties of cardiology, endocrinology, gastroenterology, general surgery, neurology, ophthalmology, and orthopedics was used. OUTCOMES: We used questions about specialists' attitudes toward primary care physicians in the gatekeeper role. A summary score of attitudes was developed. RESULTS: A total of 979 physicians completed the survey (66%). Attitudes toward primary care physicians were mixed. Relative to nonsalaried physicians, those who were salaried had a somewhat more favorable attitude toward gatekeepers (P = .13), as did physicians with a greater percentage of practice income derived from capitation (P =.002). CONCLUSIONS: Specialists' attitudes toward the coordinating role of primary care physicians are influenced by the practice setting in which the specialists work and by financial interests that may be threatened by referral restrictions. Policies that promote alternatives to fee for service and shift specialty practice toward more organized group settings may generate a common sense of purpose among primary care physicians and specialists.

Adult↗

PubMedDate not supplied

Long-term care over an uncertain future: what can current retirees expect?

The leading edge of the baby boom generation is nearing retirement and facing uncertainty about its need for long-term care (LTC). Using a microsimulation model, this analysis projected that people currently turning age 65 will need LTC for three years on average. An important share of needed care will be covered by public programs and some private insurance, but much of the care will be an uninsured private responsibility of individuals and their families--a responsibility that will be distributed unequally. While over a third of those now turning 65 are projected to never receive family care, three out of 10 will rely on family care for more than two years. Similarly, half of people turning 65 will have no private out-of-pocket expenditures for LTC, while more than one in 20 are projected to spend $100,000 or more of their own money (in present discounted value). Policy debate that focuses only on income security and acute care--and the corresponding Social Security and Medicare programs--misses the third, largely private, risk that retirees face: that of needing LTC.

Aged↗

PubMedDate not supplied

Nursing faculty practice: an organizational perspective.

After reviewing the faculty practice literature of the 1980s and finding philosophical support for practice but also growing concerns about faculty role overload, the authors report a study to identify organizational factors that influence the role expectations of faculty members about practice. A survey was sent to the deans or directors of all National League for Nursing--accredited baccalaureate nursing programs (n = 462). Of the 356 respondents (78 per cent), 224 (63.3 per cent) reported that their school had practicing faculty, but only 20 schools (8.8 per cent) required practice. Written faculty practice plans were reported by 23 schools (10.2 per cent), and nursing centers by 41 schools. Thirty-six respondents (16 per cent) reported that practicing faculty generated revenue for the school. Practice was required for promotion in 15.8 per cent and for tenure in 15.3 per cent of all schools surveyed. The study showed significant direct relationships between master's and doctoral programs and practicing faculty, but there was an inverse relationship between the presence of a health science center and schools with practicing faculty. Organizational factors relating to both the number and per cent of faculty who practiced included requiring practice, having a practice plan, and having practice as a criterion for promotion and for tenure. Revenue generation and presence of formalized practice arrangements were related to the number of faculty who practiced but not the per cent of the total faculty who practiced. The study's findings have implications for nursing education in designing organizational structures and rewards that support faculty practice.

Education, Nursing, Baccalaureate↗

PubMed1989

Public attitudes toward Social Security.

In the early years of the Social Security program, public support for old-age pensions was high but knowledge and understanding about benefits and taxes were low. Understanding has greatly increased, even though the program has expanded, and support for Social Security has remained high. Data from the surveys and polls examined in this article indicate that support for Social Security was strong even during the late 1970's and early 1980's, when a fiscal crisis generated a crisis of confidence in the public's perception of the system's ability to pay benefits in the future. The proportion of the American public declaring confidence in the program declined sharply from a large majority with confidence (63 percent) in 1975 to a minority with confidence (39 percent) in 1978. Following the restoration of program financing through the provisions in the 1983 amendments, the trend has reversed. By 1988, nearly one-half of the public expressed confidence in the future of the Social Security program. For the most part, other aspects of public opinion regarding Social Security have shown great stability over the years. The program is popular and has been well-supported. Support for the Government to spend more for Social Security has been consistently high, as has support for benefits to increase with inflation and for benefits to increase even if it means higher taxes. Many individuals rely on income from Social Security or expect to rely on it when they retire. It is clear that the public wants the program to continue. If participation were optional, about three-fourths of the population would stay in the program.

Health Surveys↗

PubMed1980

Alternative approaches to physician reimbursement under medicare: a simulation.

A simulation approach was used to compare the effects of different methods of determining reasonable charges for physicians' services under Medicare on government outlays, physician revenues, and beneficiaries' financial burdens. This is an important policy area because of fee inflation and rises in physician income. Queens County claims for 1976 and 1977 were used for this analysis. The different methods that were compared to the current method, which is the 75h percentile of weighted customary charges adjusted for the Economic Index, included a single prevailing that dispensed with specialty groupings, an unadjusted prevailing eliminating the Economic Index correction, and average reasonable charges in a base year computed with and without regard for specialty board certification. The results of the trials showed that program costs are about 8 per cent higher without the Economic Index. The single prevailing cuts government costs but substantially raises beneficiaries' out-of-pocket costs. Patients not receiving assignment were most likely to have greater burdens. The average reasonable charge approach had little effect on any of the participants and does not justify the additional expense of the shift in computer programs. As a fee schedule approach would probably use single prevailing prices, the fact that socially undesirable results are generated is significant.

Fees, Medical↗

PubMed1990

Intermountain Health Care: a multihospital system committed to rural health care.

This article describes Intermountain Health Care's experience in rural health care and outlines the accomplishments and problems that a multihospital system has experienced in maintaining its commitment to rural health care. Development of services in both administrative and clinical functions shared between referral centers and the corporate office with rural hospitals is explained and the amount of savings generated described. The challenge of maintaining hospitals with 20 beds or fewer is explained as well as how hospitals with 50 beds or more are breaking even because of the support from the system. Strategies are described to address decreasing revenues in the environment and alternatives of care available from Intermountain Health Care to the communities that cannot sustain an acute care facility are identified.

Data Collection↗

PubMed2005

Cultural influences on the bedtime behaviors of young children.

BACKGROUND AND PURPOSE: This study was designed to assess potential relationships of race and socioeconomic status (SES) to bedtime behavior from a community sample of 2- to 7-year-old children. PATIENTS AND METHODS: A previously validated sleep questionnaire was administered to parents of children enrolled in the Jefferson County, Kentucky school system. The sleep behavior of African-American (n=973) and Caucasian (n=2398) children was analyzed. Median annual income of residential zip codes was used as a proxy for SES. RESULTS: Mean age was 4.8+/-1.1 years. Two composite 'sleep behavior scores' were generated related to excessive daytime sleepiness and sleep-related behavior. Children in the lower SES group had significantly more impaired 'sleep behavior scores' than those in the higher SES group, regardless of race or age. African-American children had later bedtimes than Caucasian children with similar rise times, resulting in significantly shorter sleep duration and more excessive daytime sleepiness, independent of SES and age. CONCLUSIONS: Cultural variables impact sleep-related behavior in children. Race and SES have independent relationships with sleep behavior. Independent of SES, African-American children sleep less due to later bedtimes. SES does play a role, however, in parentally reported sleep-related behavior problems. Thus, cultural variables such as race and SES are important modifiers of sleep behaviors in children and should be addressed in sleep education programs.

Child↗

PubMed2000

The future of orthopaedics in the United States: an analysis of the effects of managed care in the face of an excess supply of orthopaedic surgeons.

Recent technological advances in orthopaedic surgery have propelled both the volume of surgical cases and their complexity, resulting in increased costs, which should naturally result in higher incomes for surgeons. However, the transition from a fee-for-service model of physician compensation to a managed care model has resulted in major shifts in economic resource allocation. An economic model of this market based on imperfect competition shows that these changes have shifted market power from surgeons to the managed care organizations. Our model predicts that practicing surgeons will retire earlier, medical students will begin to select other specialties, and innovation will be slowed. Antitrust laws limit surgeons' ability to combat this trend through meaningful collective bargaining, creating the potential for future shortages as the baby boom generation reaches retirement age and the demand for orthopaedic services increases dramatically.

Education, Medical↗

PubMed2002

Boosting uptake of influenza immunisation: a randomised controlled trial of telephone appointing in general practice.

BACKGROUND: Immunisation against influenza is an effective intervention that reduces serologically confirmed cases by between 60% and 70%. Almost all influenza immunisation in the UK is done within general practice. Current evidence on the effectiveness of patient reminders for all types of immunisation programmes is largely based on North American studies. AIM: To determine whether telephone appointments offered bygeneral practice receptionists increase the uptake of irfluenza immunisation among the registered population aged over 65 years in east London practices. DESIGN OF STUDY: Randomised controlled trial. SETTING: Three research general practices within the East London and Essex network of researchers (ELENoR). METHOD: Participants were 1,820 low-risk patients aged 65 to 74 years who had not previously been in a recall system for influenza immunisation at their general practice. The intervention, during October 2000, was a telephone call from the practice receptionist to intervention group households, offering an appointment for influenza immunisation at a nurse-run. clinic Main outcome measures were the numbers of individuals in each group receiving immunisation, and practice costs of a telephone-appointing programme. RESULTS: intention to treat analysis showed an immunisation rate in the control group of 44%, compared with 50% in the intervention group (odds ratio = 1.29, 95% confidence interval = 1.03 to 1.63). Of the patients making a telephone appointment, 88% recieved immunisation, while 22% of those not wanting an appointment went on to be immunised. In the controlgroup, income generated was 11.35 pounds per immunisation, for each additional immunisation in the intervention group the income was 5.20 pounds. The 'number needed to telephone' was 17. CONCLUSION: Uptake of influenza immunisation among the low-risk older population in inner-city areas can be boosted by around 6% using a simple intervention by receptionists. Immunisation rates in this low-risk group fell well short of the 60% government target. Improving immunisation rates will require a sustained public health campaign. Retaining the item-of-service payments to practices should support costs of practice-based interventions.

Aged↗

PubMed2004

Monkeypox in the United States: an occupational health look at the first cases.

Between May 15 and June 20, 2003, 71 suspected cases of monkeypox were investigated and 37 individuals in the United States developed laboratory confirmed monkeypox. These were the first cases of human monkeypox ever documented in the United States or in the Western Hemisphere. The disease was transmitted from small animals imported from Africa to other animals, including prairie dogs sold as pets throughout the U.S. Midwest. Direct contact with the infected animals was the method of infection, and although human to human transmission was thought to have occurred, this was not confirmed by follow up testing. Because of the link with contact with a prairie dog, initial evaluation of the disease was focused toward diseases commonly associated with this animal (e.g., tularemia, plague). Laboratory findings at the Marshfield Clinic in Marshfield, Wisconsin pointed to the presence of an orthopox. The CDC confirmed monkeypox was the infecting orthopox agent. Occupational health nurses from the Marshfield Clinic had direct involvement in the identification and follow up of employees who had direct contact with the diagnosed patients. Programs, such as a respiratory protection program initiated and carried out by Clinic occupational health nurses, were used to prevent employee exposure for Clinic staff. One Clinic employee was thought to potentially have monkeypox because of her direct contact with one of the patients. Four Clinic employees were vaccinated with vaccinia vaccine as a result of their contact with patients or lab specimens. Quarantine of the potentially infected employee and her boyfriend uncovered issues that must be addressed if other infectious diseases requiring quarantine or isolation of individuals emerge or re-emerge. These include a system to compensate individuals in quarantine or isolation who do not have any other source of income. The issue of whether workers' compensation should cover an employee who is quarantined or isolated for a potential work related exposure to an infectious disease if no disease is actually diagnosed also needs to be explored. A better system of getting state or CDC laboratory results back to the local level, including the occupational health area of the generating facility, must be developed. This will be very important if diseases such as severe acute respiratory syndrome (SARS) or smallpox should re-emerge in the United States. Occupational health nurses are an integral part of any infectious disease process occurring in the United States. The identification of monkeypox in the United States shows that any planning to detect, prevent, and treat diseases with the potential to affect the employee population must include occupational health nurse involvement.

Animals↗

PubMed1988

Predictors of prenatal care utilization.

Despite substantial evidence linking improved pregnancy outcomes with receipt of prenatal care and recent improvements in prenatal care utilization, specific subpopulations continue to receive inadequate or less than adequate care. The study reported here examined the predictive power of a set of variables describing the type of financial coverage available to the mother, attributes of the mother, father and family and characteristics of the health care system. A stratified random sample of mothers was generated from state birth certificate files and surveyed through the use of a mailed questionnaire. Stratification was designed to assure adequate representation of subgroups expected to receive less adequate prenatal care. The study findings indicate that there were deficiencies in prenatal care utilization and that these deficiencies were concentrated in specific areas and subpopulations within the state. While the majority of women in the study started prenatal care in the recommended first trimester, most did not maintain the recommended schedule of visits with their care provider. The following conditions were found to reduce the likelihood of receiving adequate care after controlling for service need: younger women (particularly adolescents); less educated (particularly those without a high school education); low income; longer travel time; Medicaid recipient; and rural resident. In addition, it was found that where one lives is a significant predictor of the adequacy of prenatal care even after controlling for all of the above variables. The authors conclude that it is important in assessing potential policy and program options for reducing differentials in prenatal care use to distinguish between economic and noneconomic barriers to utilization. Receipt of Medicaid does not assure adequate prenatal care use.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗

PubMed2005

[Dangerous, illegal captivities].

On the 21st of August 1997 the Polish legislature introduced the first animal protection law nr 724. This act however failed to specify in a clear and proper manner the problem of possession and maintenance of dangerous animals, which allows its multiple interpretations. Poland ratified the Washington Convention in 1990 restricting the trade of animals classified as endangered species. The present regulations enable illegal purchase and trade of those animals. According to the available data illegal trade of such animals, as well as the trade of products obtained from them, ranks in the third position in terms of crime generated income, only after the trade of drugs and weapons. In our country the sales of such animals have been growing at an alarming rate. The animals often get out of the control of their owners, or are abandoned by them. The presented work describes cases of reptiles being found in public places in our region. It also mentions the problem of possible dangers associated with intentional letting out of such animals in public places. The aim of the following paper is the analysis of the problem of raising of exotic animals, in particular venomous snakes and other animals, the possession of which may be dangerous not only for the owner but also for the people around. The existing laws and executive procedures have been discussed. Both, the family doctors as well as toxicologists have little knowledge as far as diagnosis and treatment of cases of stinging and biting by exotic animals is concerned. The authors suggest providing medical emergency doctors, family doctors and surgeons, with clinic toxicology programs, as well as introduction of special courses for middle medical personnel. Establishment of a central database and a database concerned with basic polyvalent serums are crucial in our country in order have the Toxicology Centers ready to face possible dangers associated with dangerous animals, and to prepare emergency solutions in cases of criminal actions involving the use of dangerous animals.

Animal Husbandry↗

PubMed2002

Biased enrollment of Medicare beneficiaries in HMO plans--implications for Medicare costs.

Policymakers assumed that the enrollment of Medicare beneficiaries in health maintenance organization (HMO) plans would generate significant cost savings for Medicare. The Health Care Financing Administration (HCFA) calculates the reimbursement to HMOs per Medicare beneficiary on the basis of individual and community-specific characteristics. Estimates of the individual-specific profitability rate for enrolling an individual in a Medicare HMO risk plan suggest that the probability of enrollment in HMOs increases with a higher profitability score. The probability of not enrolling high-loss cases is found to be high, indicating that the biased selection in HMO plans actually increases the overall cost of running the Medicare program.

Adult↗

PubMed2004

Multidisciplinary intervention for reducing malnutrition among children in the Islamic Republic of Iran.

A multidisciplinary intervention to reduce protein-energy malnutrition among children in rural areas was piloted in 3 provinces of the Islamic Republic of Iran. Based on an initial situation analysis, a range of interventions were implemented through local nongovernmental organizations, including nutrition, health and literacy education for mothers, improved growth monitoring and fostering rural cooperatives and income generation schemes. Malnutrition before and after the intervention (in 1996 and 1999) was assessed using anthropometric measurements of random samples of children aged 6-35 months in control and intervention areas. Three years into the intervention, all indicators of malnutrition had consistently decreased in all intervention areas and the prevalence of underweight and stunting was significantly lower. Control areas showed a mixed pattern of small increases and decreases in malnutrition indicators.

Anthropometry↗

PubMedDate not supplied

Strategic planning: today's hot buttons.

The first generation of mergers and managed care hasn't slowed down group practices' need for strategic planning. Even groups that already went through one merger are asking about new mergers or ownership possibilities, the future of managed care, performance standards and physician unhappiness. Strategic planning, including consideration of bench-marking, production of ancillary services and physician involvement, can help. Even if only a short, general look at the future, strategic planning shows the proactive leadership needed in today's environment.

Benchmarking↗