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PubMedDate not supplied

Self-assessment of communication skills preparedness: adult versus pediatric skills.

PURPOSE: To characterize and compare incoming residents' self-reported 1) amount and sufficiency of medical school training in clinical communication for patients of different ages, and 2) training experience and anticipated comfort level when breaking news of serious diagnoses with patients of different ages. METHOD: A self-assessment tool was voluntarily completed by residents entering Brown- and Dartmouth-affiliated residencies. Descriptive statistics were generated and 2-tailed t tests were used to compare mean responses for patient age categories within each area of questioning. RESULTS: A total of 143 (78%) of 184 residents completed self-assessments. Estimates of training time with adult patients were greater than any other patient age category and were rated most sufficient. Twelve percent and 11% of respondents reported no formal training in pediatric and adolescent skills, respectively, and more than half reported that they had never observed a pediatric or adolescent "bad news" interaction. Half of the respondents had personally informed a patient or family of a serious diagnosis, most often concerning middle-aged or elderly patients. Respondents anticipated greatest discomfort discussing serious illness in younger patients and least discomfort discussing serious illness in adult and elderly patients. CONCLUSIONS: Residents feel less prepared for and receive less training in general communication skills, particularly skills required for delivering bad news, in pediatric clinical interactions as compared with interactions with adult patients. Additional formalized training in communication skills and strategies for breaking bad news to pediatric and adolescent patients may be warranted.

Adult↗
PubMed2001

Determining the full costs of medical education in Thai Binh, Vietnam: a generalizable model.

We summarize a model for determining the full cost of educating a medical student at Thai Binh Medical School in Vietnam. This is the first full-cost analysis of medical education in a low-income country in over 20 years. We emphasize policy implications and the importance of looking at the educational costs and service roles of the major health professions. In Vietnam fully subsidized medical education has given way to a system combining student-paid tuition and fees with decreased government subsidies. Full cost information facilitates resource management, setting tuition charges at a school and adjusting budget allocations between medical schools, teaching hospitals, and health centres. When linked to quality indicators, trends within and useful comparisons between schools are possible. Cost comparisons between different types of providers can assist policy-makers in judging the appropriateness of expenditures per graduate for nursing and allied health education versus physician education. If privatization of medical education is considered, cost analysis allows policy-makers to know the full costs of educating physicians including the subsidies required in clinical settings. Our approach is intuitively simple and provides useful, understandable new information to managers and policy-makers. The full cost per medical graduate in 1997 was 111 462 989 Vietnamese Dong (US$9527). The relative expenditure per Vietnamese physician educated was 2.8 times the expenditure in the United States when adjusted for GNP per capita. Preliminary findings suggest that, within Vietnam, the cost to educate a physician is 14 times the cost of educating a nurse. Given the direct costs of physician education, the lifetime earnings of physicians and the costs that physicians generate for the use of health services and supplies, it is remarkable that so little attention is paid to the costs of educating physicians. Studies of this type can provide the quantitative basis for vital human resource and health services policy considerations.

Budgets↗
PubMed2000

A framework for assessing the performance of health systems.

Health systems vary widely in performance, and countries with similar levels of income, education and health expenditure differ in their ability to attain key health goals. This paper proposes a framework to advance the understanding of health system performance. A first step is to define the boundaries of the health system, based on the concept of health action. Health action is defined as any set of activities whose primary intent is to improve or maintain health. Within these boundaries, the concept of performance is centred around three fundamental goals: improving health, enhancing responsiveness to the expectations of the population, and assuring fairness of financial contribution. Improving health means both increasing the average health status and reducing health inequalities. Responsiveness includes two major components: (a) respect for persons (including dignity, confidentiality and autonomy of individuals and families to decide about their own health); and (b) client orientation (including prompt attention, access to social support networks during care, quality of basic amenities and choice of provider). Fairness of financial contribution means that every household pays a fair share of the total health bill for a country (which may mean that very poor households pay nothing at all). This implies that everyone is protected from financial risks due to health care. The measurement of performance relates goal attainment to the resources available. Variation in performance is a function of the way in which the health system organizes four key functions: stewardship (a broader concept than regulation); financing (including revenue collection, fund pooling and purchasing); service provision (for personal and non-personal health services); and resource generation (including personnel, facilities and knowledge). By investigating these four functions and how they combine, it is possible not only to understand the proximate determinants of health system performance, but also to contemplate major policy challenges.

Delivery of Health Care↗
PubMed1999

The integration of primary care sports medicine into an academic emergency medicine practice: academic and revenue enhancement.

OBJECTIVES: To determine whether integrating primary care sports medicine into academic emergency medicine (EM) can enhance both revenue and the academic program. METHODS: A retrospective descriptive review of all patients seen in a primary care sports medicine practice at a university hospital sports medicine clinic was done over a 24-month period. All patients seen initially in the ED for a sports injury either by the author or by another EM faculty member with follow-up by the author in the sports medicine clinic were included in the study group. The study group was analyzed for diagnoses, payor mix, and revenue generated by the ED follow-up sports medicine clinic visits. RESULTS: There were 199 patients who met the inclusion criteria. This resulted in 483 ED follow-up sports medicine clinic visits. The author practiced 13 hours/week in the ED and 16 hours/week in the primary care sports medicine practice, which resulted in 1,536 sports medicine clinic hours. The study group accounted for 20% of the total patient volume in the author's primary care sports medicine practice. There were 111 lower-extremity injuries (knee 52%, foot/ankle 40%, hip/pelvis 8%), 81 upper-extremity injuries (hand/wrist 48%, shoulder 43%, elbow 9%), and seven spine injuries. Payor mix was 47% traditional indemnity, 45% HMO, 4% self-pay, and 4% Medicare/Medicaid. Total charges for the ED follow-up sports medicine clinic visits were $44,767 ($92.68/visit) and net receipts were $30,276 ($62.68/visit). This represented 20% of the total charges and 16% of the net receipts in the author's sports medicine practice during this period. Revenue generated by the ED follow-up sports medicine clinic visits could have supported 12% of the equivalent cost of the base pay for a full-time EM faculty position. CONCLUSION: The integration of primary care sports medicine into an academic EM faculty practice can enhance revenue through the establishment of an ED follow-up sports medicine clinic while also providing an opportunity to expand resident learning experiences.

Aftercare↗
PubMed1993

User fees plus quality equals improved access to health care: results of a field experiment in Cameroon.

Since the Bamako Initiative was launched in 1988, many African countries have embarked on comprehensive primary health care programs relying, at least partially, on revenues generated through user fees to revitalize health care delivery systems. Although these programs contain two critical components, user fees and improved quality, policy debates have tended to focus on the former and disregarded the latter. The purpose of this study is to provide a net assessment of these two components by testing how user fees and improved quality affect health facility utilization among the overall population and specifically among the poorest people. A "pretest-posttest controlled" experiment was conducted in five public health facilities in the Adamaoua province of Cameroon. Three health centers which were to introduce a user fee and quality improvement (i.e. reliable drug supply) policy were selected as "treatment" centers and two comparable facilities not yet phased into this policy were selected as "controls". Two rounds of household surveys were conducted (each to 800 households in 25 villages surrounding the five study sites) to measure the percentage of ill people seeking care at the health center before and after the implementation of the policy. The experiment was tightly controlled by conducting monthly observations at each study site. Results indicate that the probability of using the health center increased significantly for people in the "treatment" areas compared to those in the "control" areas. Travel and time costs involved in seeking alternative sources of care are high; when good quality drugs became available at the local health center, the fee charged for care and treatment represented an effective reduction in the price of care and thus utilization rose. Moreover, contrary to previous studies which have found that the poorest quintile is most hurt by user fees, this study found that probability of the poorest quintile seeking care increases at a rate proportionately greater than the rest of the population. Since the poor are most responsive to price changes, they appear to be benefitting from local availability of drugs more than others.

Age Factors↗
PubMed2005

Social security: a program and policy history.

Many of the federal and state programs that provide income security to U.S. families have their roots in the Social Security Act (the Act) of 1935. This Act provided for unemployment insurance, old-age insurance, and means-tested welfare programs. The Great Depression was clearly a catalyst for the Social Security Act of 1935, and some of its provisions--notably the means-tested programs--were intended to offer immediate relief to families. However, the old-age insurance program-the precursor to today's Old-Age, Survivors, and Disability Insurance, or Social Security, program-was not designed specifically to deal with the economic crisis of that era. Indeed, monthly benefit payments, under the original Act, were not scheduled to begin until 1942. In addition, from the beginning, the Social Security program has embodied social insurance principles that were widely discussed even before the onset of the Great Depression. The first four decades of the Social Security program were, in general, ones of expansion. In fact, the program was expanded even before it became truly operational. In 1939, amendments added child, spouse, and survivor benefits to the retirement benefits authorized by the 1935 Act. Those amendments also allowed for monthly benefits to begin in 1940. Although the program was not changed substantially during the war years and the initial postwar period, the 1950s were a transformational decade in the program's history: benefit amounts were increased substantially, coverage under the program became close to universal, and a new disability insurance benefit was offered. The 1960s witnessed additional growth in Social Security, but the most important development in social insurance occurred in health insurance, with the creation of the Medicare program in 1965. Legislative actions in the 1970s had profound effects on the Social Security program and, indeed, set the stage for many of today's reform debates. Large benefit increases, a new benefit formula that was erroneously generous, and other changes in the early 1970s created a situation in which annual program costs, as a share of gross domestic product, increased during a 12-year period from about 3 percent to 5 percent. In 1977, amendments to the Act corrected the flawed benefit formula and made other changes in the financing of the system to shore up the program. Thus, the 1970s represent a watershed in the program's history-program growth gave way to increasing concerns about the program's finances. Those concerns were reflected in the amendments to the Act in 1983, which were the last major changes to the program. These amendments, based largely on recommendations from a commission chaired by Alan Greenspan, adjusted benefits and taxes to address pressing near-term financing problems faced by the system. Although the Greenspan Commission focused to a large extent on short-range issues, the resulting reforms have generated large surpluses in the program and the buildup of a substantial trust fund. However, the looming retirement of the baby boomers and several other demographic factors will, according to projections, result in the exhaustion of the trust fund by 2042.

Adult↗
PubMed2004

Knowledge-based changes to health systems: the Thai experience in policy development.

Over the past two decades the government in Thailand has adopted an incremental approach to extending health-care coverage to the population. It first offered coverage to government employees and their dependents, and then introduced a scheme under which low-income people were exempt from charges for health care. This scheme was later extended to include elderly people, children younger than 12 years of age and disabled people. A voluntary public insurance scheme was implemented to cover those who could afford to pay for their own care. Private sector employees were covered by the Social Health Insurance scheme, which was implemented in 1991. Despite these efforts, 30% of the population remained uninsured in 2001. In October of that year, the new government decided to embark on a programme to provide universal health-care coverage. This paper describes how research into health systems and health policy contributed to the move towards universal coverage. Data on health systems financing and functioning had been gathered before and after the founding of the Health Systems Research Institute in early 1990. In 1991, a contract capitation model had been used to launch the Social Health Insurance scheme. The advantages of using a capitation model are that it contains costs and provides an acceptable quality of service as opposed to the cost escalation and inefficiency that occur under fee-for-service reimbursement models, such as the one used to provide medical benefits to civil servants. An analysis of the implementation of universal coverage found that politics moved universal coverage onto the policy agenda during the general election campaign in January 2001. The capacity for research on health systems and policy to generate evidence guided the development of the policy and the design of the system at a later stage. Because the reformists who sought to bring about universal coverage (who were mostly civil servants in the Ministry of Public Health and members of nongovernmental organizations) were able to bridge the gap between researchers and politicians, an evidence-based political decision was made. Additionally, the media played a part in shaping the societal consensus on universal coverage.

Cost Control↗
PubMed2001

State and local retirement plans: innovation and renovation.

This Special Report/Issue Brief examines the universe of state and local retirement plans. It describes how these plans have developed and continue to evolve in a number of areas, including plan features, regulatory framework, governance, and asset management. While these retirement programs differ in many respects from private-sector plans, the disparity in some areas has narrowed. This report also includes a discussion of trends and the underlying forces for change. Public-sector retirement programs provide an important source of pension coverage in the United States, and are a significant part of the total retirement market: Combined public-sector retirement assets (state, local, and federal governments) comprised 29 percent of the $11.2 trillion U.S. retirement market in 1998. State and local plans are dominant in the public-sector retirement market, holding $2.7 trillion in assets, compared with $696 billion held by federal plans (both military and civilian). More than 16 million individuals are employed by state and local jurisdictions in the United States. State and local retirement plans share certain common features because of the environment in which they operate. Legal statutes, governance, and tradition all play a role in defining what is sometimes referred to as a "public-sector culture." Despite common features, there is considerable diversity among public-sector retirement plans. To attract and retain a skilled work force, public-sector employers have increased their use of defined contribution (DC) plans to supplement defined benefit (DB) plans (or, to a lesser extent, replace or serve as an alternative to them) and improve cost-of-living adjustments. At the same time, a combined federal-state regulatory framework has encouraged certain plan design features, unavailable in the private sector, which include multiple tiers for successive generations of employees in a single plan and different strategies to increase portability. State and local retirement plans reflect an increasing role by the federal government in pension system design and operation, which has led to greater complexity in such areas as Social Security participation and deferred compensation arrangements. Complexity can be expected to increase with the recent passage of P.L. 107-16, the Economic Growth and Tax Relief Reconciliation Act of 2001. The latest full-year data included in this report are for 1999 and in some cases 2000. After this report went to press, the Federal Reserve issued significantly revised quarterly data for state, local, and federal retirement plan assets, which were not incorporated in this Issue Brief.

Employee Retirement Income Security Act↗
PubMed1996

Preserving medical schools' academic mission in a competitive marketplace.

To gain a better understanding of the effects on medical schools of transformations in medical practice, science, and public expectations, the AAMC in 1994 formed the Advisory Panel on the Mission and Organization of Medical Schools and appointed six working groups to address relevant issues. This article is a report of the findings of the Working Group on Preserving Medical Schools' Academic Mission in a Competitive Marketplace, which was charged with exploring how medical schools could acquire and/or preserve an adequate patient base for teaching, research, and income generation in a competitive marketplace. The other groups' reports will appear in future issues of Academic Medicine. To understand the diversity of approaches that schools have taken to achieve this goal and to preserve their missions, the group interviewed representatives of nine medical schools, selected to represent a cross section of U.S. medical schools. The interviews took place on four occasions between June 1995 and March 1996. The information and comments shared by participants helped the working group gain insight into the fundamental issues it had been charged to address, including those of new delivery structures, what value schools offer to delivery structures, how education and research can be incorporated and supported financially, possible new pressures on relationships between medical schools and teaching hospitals, changes in faculty physicians' employment relationships and terms, and the role of the medical school in graduate medical education. In collecting and analyzing the data, the working group focused on the distinction between protecting an institution's existing enterprise and preserving an institution's core mission. This article gives a detailed overview of the information and comments each school presented, organized under the appropriate question. The working group's conclusions and commentaries on the findings follow. An appendix presents more detailed summaries of the schools' presentations, organised as case studies. The picture that emerges is complex. The working group concluded that medical schools will take a variety of approaches to define and preserve their missions. Most, but not all, medical schools will be able to secure the patient bases necessary to fulfill their missions even in a competitive marketplace. However, the nature of many of the schools is likely to change, and it is not clear whether the core missions of education and research will continue at their present levels at all schools.

Costs and Cost Analysis↗
PubMed2001

Making psychiatric epidemiology useful: the contribution of epidemiology to government policy.

OBJECTIVE: This paper aims to discuss the contribution of epidemiology to aspects of public policy that have either a direct influence on mental health and mental disorders, or an indirect effect by influencing environmental factors which influence mental health. Both kinds of public policy will need to be considered by governments wishing to protect, promote and improve the mental health of their populations. The paper draws on information from both relatively wealthy and low-income countries. METHOD: The paper defines epidemiology and mental health policy, sets out the range of government policies which may have an impact on mental health, and explores the ways in which epidemiology may contribute to mental health policy in relation to service inputs, processes and outcomes as well as to wider government policies. The paper also examines the advantages and disadvantages of different sources of data. RESULTS: There are a number of reasons to carry out large-scale surveys of psychiatric morbidity. First, effective policy should address the needs of the population, which can best be assessed by the epidemiology and the social and economic causes and consequences of psychiatric morbidity. Secondly, representative information in a defined geographic area can document the use of existing services and can estimate the extent of unmet needs and the services required meeting those needs. Thirdly, valid information on prevalence and associated risk factors of presumed causal importance allow aetiological hypotheses to be generated and tested and models developed for prevention. Finally, by repeating community surveys, it is possible to monitor the health of the population and trends. Epidemiological findings emphasize the importance of mental health policy addressing the key role of primary care, the social context and social consequences of disorder, the importance of addressing services for children, the need to reduce premature mortality from suicide and from physical illness. Epidemiological findings show that mental health and mental disorders are related to the environment both in its structural physical sense and in the sense of the social processes connected to and influenced by particular settings. Thus epidemiology can contribute to general policies on employment and unemployment, housing and homelessness, education and women's issues. CONCLUSION: Mental health policy is increasingly recognized as an essential area for countries wishing to enhance their economic, social and human capital. Epidemiological data are a basic prerequisite to informing such policies. Expert professional and epidemiological advice to ministries is essential if policy is to be rooted in the evidence for population needs, risk factors, effective treatments and services, and measurement of outcomes. It is therefore important to develop the capacity for policy work in the psychiatric profession by including public health, epidemiology and policy placements for young psychiatrists.

Child↗
PubMed1988

Evolution of a steam atmosphere during Earth's accretion.

We have modeled the evolution of an impact-generated steam atmosphere surrounding an accreting Earth. The model assumes Safronov accretion; it includes degassing of planetesimals upon impact, thermal blanketing by a steam atmosphere, interchange of water between the surface and the interior, shock heating and convective cooling of Earth's interior, and hydrogen escape, both by a solar extreme ultraviolet (EUV) powered planetary wind and by impact erosion (atmospheric cratering). The model does not include atmophiles other than water, chemical reaction of water with metallic iron, core formation, compression, and spatial and temporal inhomogeneity of accretion. If the incoming planetesimals were too dry or the EUV flux too high, very little water would accumulate at the surface. Essentially all water retained by such a planet would be through rehydration of silicates. If rehydration were inefficient, very little water would be retained in any form. Degassing of wetter planetesimals produces a steam atmosphere over a magma ocean, the energy of accretion being sufficient to maintain a runaway greenhouse atmosphere. The mass of the atmosphere is limited by water's solubility in the (partial) melt. This type of solution is produced for a wide range of model parameters. During accretion, approximately 30 bars of water could have kept the surface at 1500 degrees K. As the accretional energy input declined below the runaway greenhouse threshold, the steam atmosphere rained out. Outgassing of dissolved water at the close of accretion is quantitatively important. These models can leave from approximately 100 to more than 300 bars of water at the surface at the close of accretion. In general, most of the water accreted remains dissolved in the mantle. H2 could have escaped as rapidly as it formed only if the planetesimals were relatively dry. Consequently H2 should have accumulated until it reached chemical equilibrium with water vapor. Impact erosion (escape caused by impact) is a critical but poorly understood process. It can prevent the accumulation of a steam atmosphere if the planetesimals are sufficiently dry, or for wetter impactors if it is much more effective than we have assumed. Impact erosion of a steam atmosphere is less important; it is equivalent to a slightly drier rain of impactors. If a hypothetical Moon-forming impact took place before the collapse of the runaway greenhouse, relatively little water (approximately 30-100 bars) would have been in the atmosphere; hence little could have been lost. If the event took place later, the potential damage could have been greater.

Atmosphere↗
PubMed1997

Local cost sharing in Bamako Initiative systems in Benin and Guinea: assuring the financial viability of primary health care.

The fourth in a series of five, this article presents and analyses data on cost recovery and community cost-sharing, two key aspects of the Bamako Initiative which have been implemented in Benin and Guinea since 1986. The data come from approximately 400 health centres and result from the six-monthly monitoring sessions conducted from 1989 to 1993. Community involvement in the financing of local operating costs in the two national scale programmes is also described. In Benin and Guinea, a user fee system generates the community financed revenue with the aim of covering local operating costs including drugs. Health worker salaries remain the responsibility of the government and donor funding covers vaccine and investment costs. Village health committees manage and control resources and revenue. The community is also involved in decision making, strategy definition and quality control. In Benin in 1993, community financing revenue amounted to about US$0.6 per capita per year and generally covered all local recurrent non salary costs except vaccines and left a surplus. Although total costs and revenues were slightly lower in Guinea for the same period, over-all user fee revenue (around US$0.3 per capita per year) covered local recurrent costs (not including salaries or vaccines). A comparison of costs and revenue between regions and individual health centres revealed important differences in cost recovery ratios. In Benin, some centres recovered more than twice the local costs targeted for community financing. Twenty-five per cent of centres in Guinea did not manage to cover their designated local recurrent costs. The longitudinal analysis showed that the level of cost recovery remained stable over time even as preventive care (and especially EPI) coverage rose significantly. To better understand the most important characteristics affecting cost recovery levels, best performing health centres in terms of cost-recovery levels in 1993 were compared to worst performing centres. This analysis showed that the size of the target population of the health centre is a key determinant of cost-recovery in both countries. In addition, in Guinea the utilization of curative care linked to geographical access and in Benin the average revenue per case linked to the number of deliveries proved to be additional factors of importance. In best performing centres, financial viability improved over time in both countries between 1990 and 1993. Finally, the implications of these conclusions for the planning of health centre revitalization in West Africa are discussed.

Benin↗